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Volume III. September, 1904.

DISEASES OF THE THORAX AND ITS VISCERA, INCLUDING THE HEART, LUNGS,

AND BLOODVESSELS-DERMATOLOGY AND SYPHILIS— DISEASES

OF THE NERVOUS SYSTEM— OBSTETRICS.

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LIST OF CONTRIBUTORS.

WILLIAM T. BELFIELD, M.D.,

Professor of Surgery in the Rush Medical College; Professor of Surgery in the
Chicago Polyclinic, Chicago.

JOSEPH C. BLOODGOOD, M.D.,

Associate in Surgery, Johns Hopkins University, Baltimore, Md.

JOHN ROSE BRADFORD, M.D., F.R.C.P., F.R.S.,

Professor of Medicine and Physician to the University College Hospital, London.

JOHN G. CLARK, M.D,

Professor of Gynecology in the University of Pennsylvania, Philadelphia.

WILLIAM B. COLEY, M.D.,

Assistant Clinical Lecturer on Surgery, College of Physicians and Surgeons;
Surgeon to the Hospital for the Ruptured and Crippled, New York.

FLOYD M. CRANDALL, M.D,

Adjunct Professor of Pediatrics, New York Polyclinic Hospital; Visiting
Physician to the Minturn Hospital for Scarlet Fever and Diphtheria; Con-
sulting Physician to the Infants' and Children's Hospitals, New York.

WILLIAM EWART, M.D., F.R.C.P.,

Physician to and Joint Lecturer on Medicine at St. George's Hospital, and
Physician to the Belgrave Hospital for Children, London.

CHARLES H. FRAZIER, M.D.,

Professor of Clinical Surgery in the University of Pennsylvania; Surgeon to the
University, Howard, and Philadelphia Hospitals.

WILLIAM S. GOTTHEIL, M.D.,

Professor of Dermatology and Syphilology, New York School of Clinical Medi-
cine; Consulting Dermatologist to the Sheltering Guardian Orphan Asylum ;
Dermatologist to the Lehanon and Beth Israel Hospital, and to the German
West Side Dispensary, New York.

CHARLES PREVOST GRAYSON, A.M., M.D,

Lecturer on Laryngology and Rhinology in the Medical Department of the
University of Pennsylvania; Physician-in-Charge of the Department for Dis-
eases of the Throat and Nose in the Hospital of the University of Pennsyl-
vania; Laryngologist and Otologist to the Philadelphia Hospital.

v; LIST OF CONTRIBUTORS.

EDYV \Kl> -I \( KSON, M.D.,

Emeritus Professor of Ophthalmology in the Philadelphia Polyclinic.

II. K. M. LANDIS, M.D.,

Visiting Physician to White Haven Sanatorium : Assistant Physician to the Out-
patienl Medical Department of the Jefferson Medical College Hospital and to
the Phipps Institute; Assistant Editor of Progressive Medn ink.

RICHARD C. NOKK1S, M.D..

Assistant Professor of Obstetrics in Medical Department of the University of
Pennsylvania, Philadelphia ; Physician-in-Charge of Preston Retreat.

ROBERT B. PREBLE, A.B., M.D.,

Professor of Medicine in Northwestern University Medical School; Attending
Physician Cook County, St. Luke's, Wesley, (ierman, and Polyclinic Hospitals,
etc., Chicago.

ROBERT L. RANDOLPH, M.D.,

Associate Professor of Ophthalmology and Otology in Johns Hopkins University,
and Associate Ophthalmic and Aural Surgeon to Johns Hopkins Hospital,
Baltimore, Md.

WILLIAM G. SPILLER, M.D.,

Professor of Neuropathology and Associate Professor of Neurology in the Uni-
versity of Pennsylvania ; Clinical Professor of Nervous Diseases in the Woman's
Medical College of Pennsylvania and in the Philadelphia Polyclinic.

J. DUTTON STEELE, M.D.,

Associate in Medicine, University of Pennsylvania.

ALFRED STENGEL, M.D.,

Professor of Clinical Medicine in the University of Pennsylvania, Philadelphia.

CONTENTS OF VOLUME III.

PAGE

DISEASES OF THE THORAX AND ITS VISCERA, INCLUDING

THE HEART, LUNGS, AND BLOODVESSELS . . . .17

By WILLIAM EWART, M.D., F.R.C.P.

DERMATOLOGY AND SYPHILIS 101

By WILLIAM S. GOTTHEIL, M.D.

DISEASES OF THE NERVOUS SYSTEM 149

By WILLIAM G. SPILLER, M.D.

OBSTETRICS 189

By RICHARD C. NORRTS, M.D.

INDEX • 275

PROGRESSIVE MEDICINE.

SEPTEMBER, 1904.

DISEASES OF THE THORAX AND ITS VIS-
CERA, INCLUDING THE HEART, LUNGS,
AND BLOODVESSELS.

By AVILLIAM EWART, M.D., F.R.C.P.

TUBERCULOSIS.

The Progress of the Campaign against Tuberculosis. For good
work achieved, the past year has not been surpassed in previous records.
The crusade has been preached far and wide, and the names of its vet-
eran champions appear again at the head of numerous instructive lectures
and articles (Knopf, Bulstrode, C. Theodore Williams, Newsholme, and
many others). Its greatest and most productive event has been the
practical inauguration of the Henry Phipps Institute, the beneficent
work of which was led off by such men as Trudeau, Woodhead, Biggs,
Osier, E. Maragliano, and others. With a staff -college such as this and
with the staff which it possesses we may now look for an increasingly
efficient army.

Passing to the scene of action, no single deed can compare in its
directness of attack with that of Madame Grancher, whose benefaction
of 100,000 francs contemplates providing a country and open-air life
for the children of infected families. This is the other and more prom-
ising side of isolation — " to isolate threatened lives from their dangerous
surroundings, while making of them a more resistant generation."

"La Femme Tubereideuse" is the latest catchword, adopted by an
anti-tubercle society recently founded in Paris under high medical
patronage to popularize the co-operation of women in the work of sani-
tation, and with the help of dispensaries to penetrate the masses with
practical notions of prevention, and thus to reduce the mortality in
France in a degree comparable with its reduction in other countries.

2

18 DISEASES OF THE THORAX AND ITS VISCERA.

Prophylaxis. State Prevention and the Administrative Control of
Tuberculosis are making steady progress. Our position has been recently
reviewed by various writers (Biggs, Newsholme). Local enactments,
public and private benefactions, and a growing co-operation of local
authorities with the medical profession have to be recorded from almost
every quarter.

Isolation and Notification. The bacillus is not strictly ubiquit-
ous, but ubiquitous only in inhabited regions where phthisis prevails.1
The whole doctrine of " isolation " is contained in this fact, which is a
powerful argument for the medical officer of public health who urges,
though he does not always see his way to enforce, universal registration.
But, strangely, the same argument is also used by those who, like E. D.
Marriot," inveigh against the State-aided sanatorium movement as false
in principles, sanitation being the proper object. Secondary infection,
according to them, takes place in isolation hospitals and sanatoria, and
is likely to spread to the neighborhood. To obviate any such danger,
the French " Commission Permanente" has ordained " isolation within
the general hospital,"3 in the shape of separate rooms or wards for the
consumptive.

Do Hospitals or Sanatoria Breed Infection, or do they Scatter It f
On simple questions of common sense, of practical sense, and of man-
agement such as this it is hardly profitable to argue. Hospitals may
be made by our deed the best or the worst of things. But they are
undeniably capable of protecting the public much more efficiently than
the houses from which they derive their tenants.

The risk of infection in the open is infinitesimal even in the case of
considerable aggregations of cases, as in the altitude resorts. Although
erroneus statements are circulated as to the spread of tuberculosis in
the district of Davos, in spite of authoritative statements to the con-
trary, not a few are deterred from using its advantages by the thought
of the number of invalids. Nevertheless, it is significant that those
with local knowledge bring with them their young families, fearless of
infection and in the well-grounded expectation of considerable benefit
to the health of the children.

The spread of tuberculosis in the open air is practically unknown.
As stated by C. Fraeukel, "it is inside the house, among families, in
factories, workshops, and prisons, among people wrho live, work, and
sleep in badly kept and uncleaned rooms that infection takes place.

1 The ubiquity of the bacillus is now denied by Fliigge (Deutsche Wochenschrift, xxx.,
No 5), who endeavors to prove that the dust of streets, houses, and railway carriages is
less infections than had been represented, and that the chief danger of infection is within
the immediate vicinity of the patient.

s British Medical Journal, February 27, 1904.

* Semaine Medicale, February 10, 1904.

TUBERCULOSIS. 19

As soon, however, as the bacillus has passed the threshold of the house
it has lost its terrors, and only in exceptional cases may it find its way
again into the human organism."1

Can Registration Operate Adversely in the Spread of Phthisis t This
question is necessitated by May's remarks2 on the failures of registra-
tion and disinfection : " The prevention localities are ear-marked by a
high pneumonia death rate during the last ten years, and in eight out
of the thirteen prevention localities, viz., Philadelphia, Boston, Buffalo,
New Jersey, Baltimore, Louisville, New Haven, and Cincinnati, there
has been a total increase of 88 per cent, of phthisis during the last five
years." Further inquiry must be stimulated by this statement if it
should be confirmed.

Bacillophobia is pressing itself upon our attention as a new social
complication.3 Its unpleasant results consumptives must be prepared
to encounter at each step of their pilgrimage : in trains, in hotels, and
in private residences. It may prove sufficiently serious to deter some
of them from seeking distant climates. Already in the Riviera there
is an increasing reluctance on the part of the hotel-keepers to receive
sufferers from tuberculosis, and this evil is but too likely to grow.

S. A. Knopf, in his paper "A Plea for Justice to the Consumptive,"
refers to the three forms in which phthisiophobia crops up : in the
officialism of the State, in the helpless ignorance and dread of the indi-
vidual, and sometimes, unfortunately, in the extreme views of certain
professional men. The consumptive is not so dangerous a person as he
is apt to be taken for. After having alarmed the community to a con-
sciousness of the dangers, we must now inculcate coolness in facing them.

The Psychical Relations of Tuberculosis in Fact and Fiction are treated
in an instructive and attractive vein by G. A. de Santos Saxe.* On
the question whether the consumptive should know his condition, C. P.
Ambler5 is positive that the patient should be fully informed, for his
own sake as well as for that of others. As a fact, the " Spes phthisica,"
which in days gone by was the soul's instinctive protest against our
professional disbelief in any cure for phthisis, is now so firmly built
upon rock that no fear can disturb the consumptive's assurance, and
most of them take a keen interest in watching their own case. The
subject is "uncanny" much more to the healthy.

The Points to be Observed by the Family of a Tuberculous Patient are
well set forth by C. P. Ambler.6 They include the guarding of food

1 Tuberculosis, December, 1903.

* New York and Philadelphia Medical Journal, September 26, 1903.

* Julius Friedlander, Tuberculosis, vol. i., No. 10.

4 New York and Philadelphia Medical Journal, August 1, 1903.

5 Journal of the American Medical Association, September 12, 1903.

6 Medical Record, December 19, 1903.

20 DISEASES OF THE THORAX AND ITS VISCERA.

and of cooking and eating utensils against all chances of contamination;
the disposal of contaminated articles, of sputum, and of dust from the
patient's room ; the avoidance of cough as much as possible, and of all
kissing on the part of the patient.

The ory for " isolation" is grating upon the nerves of the public.
Alarm sometimes amounting to terror is one of the fruits of the cam-
paign, and in the end public opinion may put that pressure upon the
State which the State has hitherto been shy to impose upon the public.
Meanwhile the pressure is felt by the individual whose misfortune is
his only offence.

The Treatment of Pulmonary Tuberculosis in the Individual.
To this there are four aspects: (1) Prevention of infection; (2) protec-
tion after infection against the onset of persistence of catarrh and pneu-
monia, i. c, against mixed infection; (3) artificial cure or suppression
of the infection ; (4) natural cure by invigoration, that life may bear
down the infection. All these objects are in some degree served by the
open-air and sanatorium treatment, which is mainly directed toward the
fourth of them, but at the same time is thoroughly efficient in connec-
tion with the first so far as it concerns the safety of other individuals.
But a more strenuous pursuit of the two objects is indicated.

1. Individual Prevention can be secured by an open-air life, with
sufficient food, and with good air to sleep in. Short of this the only
absolute safeguard is immunization, which v. Behring has but hitherto
labored in vain to provide.

" Latent tuberculosis " cases, during their sometimes long periods of
incubation after infection, are doubtless, as urged by v. Behring,1 a
standing danger to the community. This cannot be met by sanatoria
or any other method except that of individual immunization, which
would secure for infants the same protection as that conferred upon
calves by the use of immunized cows' milk. In the calf, v. Behring
finds that the incubation period after infection and prior to the tuber-
culin reaction being successful may extend to three months. A yet
longer time would elapse before " open" tuberculosis was declared by
its symptoms, if the disease ever came to that stage. As a fact, merely
infected calves do not necessarily become phthisical, unless accidentally
depressed in their vitality. He also calls attention to the demonstra-
tion by Cornil, fourteen years ago, of the passage of tubercle bacilli
through unbroken mucous membrane. Doubtless we should bear in
mind this danger from the " incubating cases;" but, after all, though
they breed the poison, they do not scatter it broadcast, and their number
would soon decrease were it possible for all " open cases" to be strictly

1 Berlin, klin. Wochenschrift, 1903, No. 10.

TUBERCULOSIS. 21

segregated, v. Behring himself is in favor of isolating the incurables for
the protection of the mass, just as lepers were isolated in the Middle Ages.

2. Protection after Infection. When tuberculous invasion has
occurred our first duty is to provide, if possible, against the superven-
tion of pneumonia and catarrh with their disastrous train. It is in this
direction that climatic help is invaluable. Let there be no delay in
removing the tuberculizing subject to the protection of the pure and dry
air of the altitude, where the bronchioles are soothed and catarrh is pre-
vented, or to that of any climate which will act in the same way for
the individual in question.

3. The Remedial Treatment, including the artificial cure, aims,
first, at arresting the pneumonic process and healing the catarrh and
the septic ulceration, while restoring the depressed vitality to the level
of efficient resistance. In both these objects climate is again the most
potent aid. But in the worst cases neither any open air nor the best of
climates can avail to heal the tuberculosis or kill the bacillus in the
tissues. The curative treatment still eludes our efforts. It can only
be found by persistent investigation and clinical study.

4. The Natural Cure by Invigoration, "Open-air," " Sana-
torium," " Dispensary," and " Home Treatment." A return has
to be made to more primitive conditions. " Tuberculosis is a house
disease." If some Eden could be found where life could be conve-
niently spent in the open, and the night a la belle etoile, no further cure
would be required. But even prehistoric man had t3 seek shelter, and
this necessity exists for us over the greater part of the earth's surface.
The ideal of a purely open-air life, though practically unattainable, is
closely studied by certain " methods on primitive lines." The "tent-
life" system has been before us for some time, both for the ordinary
poor on BlackwelPs Island and for the consumptive insane at the Man-
hattan State Hospital1 under the management of II. B. Wright and
C. Floyd Haviland. S. A. Knopf's2 "half-tent" is a valuable piece
of furniture for the open air. Tent-life is also fully described by
J. Edward Stubbert in the Medical Record for July 4, 1003, particu-
larly in connection with children with medical or surgical tuberculous
affections (S. A. Knopf, A. H. Tubby, and others). Then, again, the
" Family Colonies" on the Rigi are favorably reported on by H. Erni3
after an experience of ten years. The transition from " tent-life" to
" tuberculosis in camps," now under discussion, is an obvious one.4

1 Lancet, May 2, and October 10, 1903.

2 New York and Philadelphia Medical Journal, November 28, 1903.

* Semaine Medicale, vol. xxiii., Nos. 23-24.

* The fire-escapes of tenement-houses are suggested by Alfred Meyer ( Medical News,
July 4, 1904) as a possible means of providing open-air accommodation. But the law
would hardly permit their being diverted from their proper purpose.

22 DISEASES OF THE THORAX AND ITS VISCERA.

It cannot be gainsaid that these methods are recommended by their
cheapness and are not " ultraprimitive " for the lower class. Their
success lends an argument to sonic critics who represent expensive sana-
toria as being a " waste of lives and money/' and who advocate the
hut or chalet system.1 Sir William Church, reflecting a widespread
feeling, has expressed himself in favor of inexpensive buildings when-
ever suitable.

Sanatorium, Asylum, Open-aib Station, and Dispensary.
These seem to be our four public health requisites, according to opinions
now being widely accepted in both hemispheres (Hermann M. Biggs,
C. Theodore Williams, H. T. Bulstrode, and many others). If only
notification so persistently desired (Newsholme, Findlay, and others)
could be secured, advanced phthisis might largely be segregated in
asylums (as suggested in Australia), threatened phthisis forestalled at
open-air stations, and incipient and confirmed cases treated at country
sanatoria or assisted and visited in towns from dispensaries (Biggs).

The Sanatorium System, inaugurated by Brehmer, and elaborated by
Dettweiller, Trudeau, and others, is capable of every degree of simplicity
or of perfection, and might, therefore, occupy the whole field of treat-
ment. It is indispensable for those whose health or circumstances ex-
clude the thought of any rough living. The "home treatment" is
confined to narrower possibilities. Yet it is at present, as stated by
Osier,2 the treatment for the masses. It is inferior to the best sana-
torium treatment3 for many obvious reasons, but even in large towns,
where it is least favored by atmospheric conditions, we should not de-
spair of greatly increasing its success. Toward this end the "dispen-
sary system " is a valuable aid, and its educational and general work is
commended from various quarters.4

Selection of cases and separate institutions for the early and for the
chronic cases is the requirement voiced by Bulstrode,5 De Lancey Roch-
ester,6 and others. Indeed, the latest sanatorium enactment in Minne-
sota7 provides that only patients suffering from incipient pulmonary
tuberculosis shall be received as patients in the sanatorium. If this
principle of selection could be universally carried out simple arrange-
ments would suffice for the early milder cases which are in the majority,
and more attention and money could be expended upon the complicated
treatment needed by the severer cases. In conclusion, three kinds of

1 C. Reinhardt, The Health Resort, October, 1903.

2 Medical News, December 12, 1903.

3 "William Porter, Journal of Tuberculosis, July, 1903.
* James A. Miller, Medical Record, August 22, 1903.

5 Loc. cit. 6 American Medicine, October 10, 1903.

7 Journal of the American Medical Association, December 5, 1903, p. 1432.

TUBERCULOSIS. 23

institutions are really indicated : 1. Simple "open-air" and "tent-
life " stations for the earliest and mildest affections. 2. Asylums for
the hopelessly advanced. 3. Elaborate sanatoria for all other degrees.
Sanatorium Percentages of Care. E. L. Trudeau, in the first lecture
before the Henry Phipps Institute, on October 5, 1903, referred to his
own favorable results,1 viz., a permanent recovery in 31 per cent, of all
cases, and in QQ per cent, of the incipient cases. This achievement Osier
thought was due to " his possessing the great heart and the two great
thumbs " which are essential to sanatorium management. Burton Fan-
ning, of Mundesley,2 dealing with cases detected and well directed from
their earliest stages, estimates that 75 per cent, can be restored to last-
ing fitness for work, and some 90 per cent, able to survive indefinitely
if careful to adhere to the best rules of life.

The Subsequent History of Cases of "Arrested Tuberculosis" bears
directly upon the sanatorium question. Vincent Y. Bowditcb's3 report
on seventy-nine cases treated from 1891 to 1902, at an elevation of less
than 300 feet, at the Sharon Sanatorium (being 48.17 per cent, of cases
discharged), is usually favorable in the instance of sixty-six of the cases,
as a result of continued attention to hygiene. This is a demonstration
of the capabilities of cold-air treatment without travelling far from
home.

Combination in Sanatorium Studies and Statistics. The time is ripe
for making this suggestion, which, from various aspects, must have been
in the minds of many. In my own it arises from a strong belief that
in the severe cases much more could be done even now over and above
the mere open-air treatment, originally advocated by Parrish, Boding-
ton, and Richardson, as a substitute for the hopelessly inefficient
therapeutics of those days. The " wide differences in clinical and
therapeutical practice at sanatoria," pointed out by Kelynack,4 are
inducements not so much to "^scientific uniformity," which is not yet
within sight, as to combined scientific consultation on a large scale.
For this the Henry Phipps Institute is an eligible focusing centre, and
we need its like elsewhere. As an instance, we may take the subject
of the planning of sanatoria.

The Model Sanatorium is ably described in many recent papers, and
many of them not differing very widely in their general plans and
details, are now in construction. The ideal sanatorium is a less con-
crete notion which we shall be able better to define as soon as the
methods of curing phthisis, whatever they may prove to be, are revealed

1 Lawrason Brown, Journal of the American Medical Association, November 21, 1003.

1 Lancet, August 15, 1903.

3 Journal of the American Medical Association, November 14, 190".

* Therapeutic Society, January 19, 1904.

•24 DISEASES OF THE THORAX AND ITS VISCERA.

to us. Hitherto our greatest achievement has been to enable our
patients to get well on the strength of their own vitality.

Sanatorium Building is becoming an important branch of architecture.
Its study, which was stimulated by the Wehrawald controversy, and
especially by the King's prize, may never be concluded, though it has
made considerable progress ; but the description by C. Theodore Wil-
liams,1 to whom an active participation in the planning of the King's
sanatorium for the middle class, and of the Brompton Hospital Sana-
torium for gratuitous patients has given considerable experience, may
be taken as that of an " up-to-date" sanatorium of the average kind.
But views as to policy differ and are independent of architectural plans.
To make the money go as far as possible toward multiplying the oppor-
tunities for relief implies light and temporary structures rather than
monuments worthy of the Romans. The essentials, viz., all that apper-
tains to sanitation, hygiene, and protection from weather must be pro-
vided unstintingly, but where land is inexpensive much saving may be
effected by spreading horizontally rather than vertically with our
buildings.

Tent-life in the strictness of that term is not to be recommended indis-
criminately. A tub may answer the purpose of a tough mortal like
Diogenes, not of a consumptive. The mind needs to be raised as well
as the energies of the body, and the sanatorium should impress the
patients as a decided improvement upon the scanty comforts of home,
and as a palace rather than a prison. But all this can be secured with
varied structural arrangements on the " bungalow" or on the " three
or more story " plan, in the scattered or in the continuous order. No
single uniform style can be urged. Different climates and situations
call for totally different architectural methods. The colder the climate
the greater becomes the complexity and the expense of building, owing
to the difficulties of heating and of drainage.

In Germany there are now, v. Behring states, fifty-seven sanatoria in
active operation, and twenty-seven approaching completion, besides
four seaside convalescent homes.

France is rather far behind. According to A. F. Plicque and Ver-
haeven,2 even including coming additions, there are only twelve paying
sanatoria (with 492 beds) and only eighteen poorer class sanatoria (with
1720 beds).

The Combination of Open-air, Climatic, and Sanatorium Treatment.
It has been customary to prescribe these methods singly, but this has
never appeared to me to be fair to the methods nor to the patients.

1 Lancet, January 30, 1904.

2 La Cure de la Tuberculose, etc., Paris, C. Naud, 1903.

TUBERCULOSIS. 25

If sanatorium treatment is good, meaning by this the scrupulous detail
of general and special hygiene, then how much better its results if com-
bined with open-air treatment either' in the native or in any more desir-
able, climate. Excluding always convalescence and self-cured attacks,
all hard-hit cases claim to be allowed every inch of advantage, so diffi-
cult is it to cure some of them, and, therefore, a combination of at least
two, but, better still, of all three methods.

Sanatorium and Native Open-air are an excellent combination as dis-
tinct from open air pure and simple, since distant travel is denied to the
majority. But under this is not to be understood any perfunctory and
purely nominal sanatorium treatment, nor that which is systematic
and automatic and applied indiscriminately to all. I have in mind
only the most carefully adjusted and personally conducted individual
case-management. Where this is carried out earnestly experience is
garnered which in time will fructify and may succeed in rivalling the
climatic results.

Individualization is the first essential for success in sanatorium treat-
ment in whatever place it may be carried out, and not least in distant
climates. "A great head" is needed in him who may have it in his
power to make or mar the chances of those committed to his sanatorial
charge, in addition to those qualifications of sympathy and firmness so
picturesquely described by Osier. Each day that goes by is the bad
case's most valuable day for the work of recovery, whether that day's
work should be absolute rest or any other form of treatment. None
of the precious days should be wasted.

"Climatic Treatment is essentially an individual question. This is
too often overlooked by those with insufficient knowledge of the
patients or of the climates. For each of our patients there are right
and there are wrong climates, and this also applies to the various stages
of their disease. General rules cannot be rigidly formulated ; each case
must be studied for itself, as well as each climate, though the latter task
could only be achieved by wide co-operation. The fulfilment on a
large scale of this ideal lies in the future, but we now and again obtain
samples of the marvellous effects which may be looked for from the
perfect adjustment of the climate to each individual requirement."

Meanwhile we are restricted to certain general principles of selection
and to our experience of various well-known climates, the description
rather than the number of which has been added to during the past
year.

The value of " climatic" as distinct from mere " open-air" treat-
ment will be receiving again the attention due it, which was diverted
for a while by the fervid belief in the home and sanatorium open-air
gospel.

otf DISEASES OF THE THORAX AND ITS VISCERA.

X. Loewy1 discusses mountain and sea climates, and Saake2 in an
important investigation compares the valley and the mountain air.
Elster and Geitel'a pioneer experiments had proved that atmospheric air
contains radioactive substances j Saake has now shown that with in-
creasing altitudes it contains from three to five times more of them
than in the valley. Moreover, the increasing; difference in electric
tension between air and earth also favors the accumulation of radioactive
substances at the surface of the body, and these have been shown by
Danysz to be stimulants to tissue and function. Thus an explanation
is Pound for much of the benefit accruing from mountain air, and pos-
sibly mountain sickness may be connected with the same agencies.

The Contraindications of an Altitude Climate are in addition to indi-
vidual nervous intolerance: (1) Age; (2) cardiac complications ; (3)
laryngeal tuberculosis ; (4) advanced conditions ; (5) acute and rapidly
progressive destruction (R. Bellamy3 and others).

The Contraindications of a Sea < Umate exist, according to Robin,4 in
the majority of consumptives in the shape of an excessive metabolic
activity. This is stimulated by sea air and bathing, which are there-
fore allowable only in " about 8 per cent, of the cases, those with nor-
mal or torpid metabolism." Convalescents may also derive benefit from
short stays at the seaside. Here, again, a comment is called for in favor
of " selection," for seaside resorts differ from each other perhaps more
than any other climates.

The "Arctic Treatment," that strauge fashion bred of the emulation
among patients for perfection in their cure, has, I find on revisiting
Davos, yielded at last to counsels of common sense. Long hours in
the open Liege-halle after sunset, and open windows with no fires
in the freezing bedrooms, are no longer the order of the day. In itself
the inhalation of intensely cold air may in debilitated subjects chill the
entire body below its power of reaction, and wraps may then no longer
suffice to maintain animal heat. Much irreparable harm may have
resulted from these self-imposed hardships.

" Ne quid nimis "3 applies here perhaps even more than in respect
to the abuse of overfeeding.

The Specific Therapy of Tuberculosis and Vaccination against the
Disease. E. Maragliano6 again recently at the Henry Phipps Insti-
tute declared his belief that both these objects will soon be shown to be
attainable by an extensive clinical trial of the harmless vaccination

1 Deutsche med. Wochenschrift, 1904.

5 Miinchener med. Wochenschrift, January 5, 1904.
■ Medical News, July 11, 1903.

4 Bulletin Acad, de M<?decine, 1904, vol. lxviii., No. 9.

* W. H. Prioleau, American Medicine, November 21, 1903.

6 Medical News, April 2, 1904.

TUBERCULOSIS. 27

method which he proposes. F. Piera1 strongly advocates the serum
which is widely believed in in Italy, where an institute exists for its
free distribution. It is not claimed that advanced cases with excava-
tions can be cured by it.

Marmorek's Antitubercle Serum is being tried in various countries
since his paper before the Academie de Medecine on November 17,
1903, and his lecture at St. George's Hospital, London, on March 28,
1904.2 The antitoxic serum is obtained from horses injected with the
filtered culture, free of bacilli, but containing the toxin produced by
growing a strain of " young bacilli" in a medium consisting of leuko-
toxic calf serum and glycerin liver bouillon. Marmorek regards the
pyrexia following tuberculin as really due to this toxin which the
tuberculin is supposed to excite the bacilli to secrete.

A Novel Bacterial Treatment has been elaborated, and is set forth in
an interesting paper on "The History of the :i--bacillus by S. J.
Maher."3

In the Montreal Medical Journal for July, 1903, Nicholls gives us
an account of an experimental study of the effect of the blood serum of
normal and of immunized goats in modifying the progress of tuberculous
infection. His experiments claim to show that it is possible to pre-
pare a serum possessed of antitoxic properties.

Tuberculin Treatment has been combiued with other remedies by
Mitelescu4 and by F. M. Pottenger.5 The latter has used with advan-
tage Colin Campbell's intratracheal injections, solutions, and postural
method.

Tuberculin and Creosote Treatment Combined (Marechal's Method).
S. Beruheim and Quentin6 have had better results with this than with
any other plan. Injections of creosote phosphate (1, 2, and finally 3
c.c.) are made on three successive days, and tuberculin (0.0025 gradu-
ally increased) every fourth day.

The Hygienic Treatment. A note of reaction against exaggerated
exclusiveness in treatment has also been sounded from Gorbersdorf
by R. J. Petri,7 who thinks that the " Liege Kur" has been overdone,
and recommends a moderate amount of exercise, under careful super-
vision as regards the effect upon the heart and the respiration.

The Merits of Exercise and the Merits of Lung Exercise in Pulmo-
nary Tuberculosis are questions ill suited for aphoristic dieta and not
wisely to be answered without reference to the individual patient, and

1 Gazzetta d. Ospedale, October 5, 1903. 2 Lancet.

1 New York and Philadelphia Medical Journal, January, 1904.

4 Deutsche raed. Wochenschrift, vol. xxix. p. 22.

5 American Medicine, September 19, 1903.

6 Bull. Gen. de The"rap., vol. lxxii., No. 10.

T Die Prognose der Lungen Schwindsucht. Vogel und Kreienbrink, Berlin, 1902.

28

DISEASES OF THE THORAX AND ITS VISCERA.

to each daily stage in his cure. Norman Bridge1 takes a safe position
in deprecating pulmonary gymnastics as a rule of treatment, and
J, MjoenV recommendation of frequent rapid uphill walks, increased
until nearly the whole day is spent in walking, may he denned as a

typical " kill or cure method."

Raw Mat, which is finding increased favor, and has its latest advo-
cate in Chalmers Watson,8 and recently also in D. Lloyd Smith,1 has

Fig. 1.

Bed-Punkah.

been so largely prescribed in the Paris Hospital as to cause an official
inquiry as to the desirability of using horse flesh.

Raw Milk is regarded by v. Behring as the vehicle of the bacillary
infection in infants, their imperfect alimentary epithelium proving an
inefficient barrier.

Stagnant Air. The Bed-Punkah was extemporized in a London fog
by myself5 for a patient undergoing the home cure, and was kept freely
syringed with turpentine (3 parts) and eucalyptol (1 part) with such
good effect that it was afterward in constant use. It will probably be

1 Medicine, Detroit, Nov., 1903. * Zeitsch. f. Tub. u. Heils., Bd. iv., H. 3.

* Lancet, May 14, 190.4. * Ibid., October 10, 1903.

5 British Medical Journal, May 21, 1904.

TUBERCULOSIS.

29

found a boon against stagnant air in summer as well as in winter.
The small sheet fastened to the top of the window frame hangs loosely
over a short length of India-rubber tubing, which gives it a maximum
swing with a minimum pull (Fig. 1).

Stoker's Cubicle, for the Treatment of Consumption by Treated Air,1
is supplied with dried and ozonized air, at a slightly reduced pressure,

Fig. 2.

Stoker's cubicle.

in which the patient can spend night and day or only part of his time.
The results reported by Stoker are striking as regards gain in weight
" without stuffing," reduction of temperature and of expectoration, and
diminution or disappearance of bacilli from the sputum (Fig. 2).

The Inhalation of Thorium Nitrate Emanations. Gordon Sharp's2
two cases treated in this way, according to a suggestion by F. Soddy,3 do
not carrv conviction as undoubted cases of pulmonary tuberculosis
(Fig. 3). The method therefore stands upon its trial.

1 Medical Press and Circular, November 11, 1903.

2 British Medical Journal, March 19, 1904.

Ibid., July 25, 1903.

30 DISEASES OF THE THORAX AND ITS VISCERA.

The ( hjurative Local Action of Sunlight cannot be obtained for the lung,
as in the case of the larynx (M. I. Sorgo,1 of Vienna), or on that of
surgical tuberculosis successfully treated by A. Mobroff in the Crimea
(Roussky Vratch), though general insolation is a recognized aid.

Finsen's Concentrated Chemical Lhjht It<ti/s are used by Otto -Inettner2
for one hour daily locally to the apices as one of his most valuable
adjuncts to treatment.

The High-frequency Current Treatment. We arc not supplied with
any published evidence of striking success from this treatment unaided.3

Tntralaryngeal Injections of Antiseptics, and Low-tension, High-fre-
quency Currents. The injections were administered by J. Cunningham
Bowie4 twice daily, and the electricity once. Jle says : " The arrest
of the lesion is brought about more quickly by this combined treatment

Fig. 3.

300 c.c. (17.598 oz. ) containing 100 grams (3J oz.) thorium nitrate in solution. The
outlet tube (the smaller) acts as a mouth-piece. The inlet (the larger tube) should be
straight, not bent as in the drawing.

than by the use of antiseptic oils alone, and my experience shows that
the high-frequency currents promote its healing." The amperage of
electricity passed through the pulmonary structures varied from 300 to
800 milliamperes at a pressure of from fifty to seventy volts, and the
time of each application was from ten to twenty minutes.

The Medicinal Treatment. Medication is condemned as harm-
ful by Maragliano, and, according to G. Gemelli,5 this may be proved,
as in the case of iodine, turpentine, creosote, and sodium cacodylate, by
the " drug-serum test" (the serum being obtained from animals under
the influence of a given drug).

Sanatorium authorities discourage medication on very plausible diet-
etic grounds. On the other hand, testimony is not wanting as to the
beneficial action of various internal remedies.

1 Semaine Medicale, December 23, 1903.
' Journal of Tuberculosis, April, 1903.

3 A Discussion on Electric Methods of Treatment, British Medical Journal, October
24, 1903.
* Lancet, October 31, 1903. s Gazzetta d. Ospedale, xxiv.

TUBERCULOSIS. 31

Iehthyol. James Burnet's1 advocacy is based upon thirteen cases
treated with eight to twenty grains in capsules four times daily. He
regards the effect as vasoconstricting and anti-inflammatory, while
favoring general nutrition. Rosenberg2 administers iehthyol in water.
His experience is favorable.

The Formaldehyde Treatment has three modes of application : 1. By
inhalation or vaporization (chloroform, 1 part; formalin, 1 part: rec-
tified spirits, 2 parts, and a few drops of ammonia). 2. By intravenous
injection (5 c.c. of 1 : 2000, increasing to 1 : 1000 formalin). 3. By
cataphoresis. The last method has not been used by Chowry Muther,3
who has had some good results with the others.

Iodoform, abandoned for so many years, is now urged again as an
effectual remedy by T. W. Dewar4 as a daily intravenous injection (5 to
7 minims of a pure, fresh iodoform, 1 : 7 ethereal solution, increasing
to 30 minims, rarely more) for six months or a year. Further clinical
reports will be instructive. Those supplied by Dewar are striking.

Sodium Olnnamate was injected subcutaneously by Krone5 in a few
cases with good results. Landerer's intravenous method finds its
most emphatic advocate in G. Brasch,6 who increases the dose from
1 mg. to 10 mg. (or seldom 15 or even 20 mg.). The results are rapid
and manifest except in hopeless cases. He has treated fifty-two patients.
Sodium cinnamate in a 70 per cent, glycerin solution for subcutaneous
injection in phthisis is still recommended by Drage,7 who gives particu-
lars of another favorable case, and points out that the early cases are
the most likely ones to be cured.

Systematic Soap Inunctions with white potash soap (or with a solution
of it in spirit), followed by a lukewarm bath or douche two or three
times a week, according to Kappesser's method, is regarded by V. Czerny
as a home remedy for tuberculosis hardly second in value to sea or
mineral baths.

Overcharging the Blood with CO* is advocated by H ugo Weber," and
he contends that his percentage of cures (60 per cent.) is an improve-
ment upon sanatorium treatment itself. His first method is the admin-
istration of levulose (one-half ounce or more daily) ; his second, the
injection twice daily "under the adipose layer" of 10 c.c. pure
liquid paraffin, which he terms " antiphthisicum." Though " as many
as 200 injections have sometimes been needed," the cure of tubercu-
losis would indeed be welcome even at that cost.

1 Lancet, August 8, 1903. 2 Medical Record, November 21, 1903.

8 New York and Philadelphia Medical Journal, November 14, 1903.

4 British Medical Journal, November 21, 1903.

5 Miinchener med. Wochenschrift, March 3, 1903.

6 Deutsche med. Wochenschrift, February 25, 1904.

T Lancet, May 23, 1903. 8 Zeitschrift f. Tub. u. Heilst,, Bd. iv., No. 6.

32 DISEASES OF THE THORAX AND ITS VISCERA.

Garlic is urged as a prophylactic by Giulio Cavazzani,1 whose first
advocacy was published in 1900, and had some support on the strength
of favorable experiments on guinea-pigs. H. R. Beale2 and \V ' . C. Min-
chin have used it with apparently good results.

Adrenalin for haemoptysis is found efficacious internally by A. C. Bird
and ( rraeser.8

Etiology and. Diagnosis. ' The New Nomenclature of the
Stages of Pulmonary Tuberculosis adopted by the Committee of
the American Climatological Association5 recognizes in addition to
three stages an incipient stage of slight physical and subjective signs,
with history indicative of pulmonary tuberculosis. As regards the re-
sults of treatment the conditions are to be classified as progressive,
quiescent, arrested, or apparently cured.

A. Moeller,6 after testing the degrees of the virulence of bacilli de-
rived from various kinds of human tuberculosis, arrives at the 'conclu-
sion that the form of tuberculosis appears to be determined by the
constitutional peculiarities of the patient rather than by the virulence
of the bacillus.

MarmoreWs Rapid Test for the Tuberculous Character of Fluids con-
sists in injecting a susceptible guinea-pig with the suspected fluid, and
fifteen, or better thirty, minutes later injecting directly into the brain
one-eightieth of a drop of tuberculin. The temperature rises in any case,
but if bacilli be present it will rise from 101° to 104° F. or higher.
If the interval be prolonged beyond half an hour the reaction is weaker
in proportion to the delay, and after twenty hours it is hardly percep-
tible if obtained at all. But at a much later time the reaction may
occur, the bacilli being again set free by the disintegration of the pha-
gocytes which had captured them.

In Nattan-La?rier's Rather Less Quick Method,7 based upon the active
multiplication of bacilli in the secreting mammary glands, four days
elapse before the injection of tuberculin. As regards the value of
oscillations of temperature as a test, may not these occur from various
other causes, particularly in laboratory animals ?

The Power of the Roentgen Rays to Demonstrate the Earliest Pulmonary
Invasions (1) by the limitation of the diaphragmatic excursion ; (2) by
the altered slant of the ribs, and (3) by the mottlings of the pulmonary

1 Policlinico, April ; Lancet, January 9, 1904.

2 Lancet, February 27, 1904.

3 British Medical Journal, February 3 and 6, 1904, and Epitome, November 14, 1903.

* The Report on Bacteriological Etiology has been excluded for want of space.
5 Medical News, April 30, 1904.

• Zeitschrift f. Tuber, u. Htilst., Bd. i.

7 Soc. de Biol., February 5, 1904 ; Presse MeU, December 5, 1903.

TUBERCULOSIS. 33

transparency, has again been attested by J. F. Halls Daly,1 and in a
recent paper by Green and Brooks.2

Early Diagnosis according to the usual methods is described by Sir
Isambard Owen, C. G. H. Baumlez,3 H. Edwin Lewis,4 C. Theo-
dore Williams,5 O. Roepke,6 Freymuth/ who uses tuberculin, and
A. Schmidt,8 who refers to the occurrence of instances of its failure.

Enii's Klopf-phoenomen or " Signe du Tapotage," angliee "chest-
rapping," is thought by its author9 to be of some value not only as a
means of diagnosing cavities when latent, but also as a method of treat-
ment. He finds that where suitably and systematically practised, the
gentle rapping is best carried out by the vibrations of the handle of a
paper-knife, which is allowed to drop on the chest while its point is
slightly balanced between the fingers. This sets up each time the
characteristic immediate fit of coughing, which may gradually empty
the cavity and change the nature of the expectoration. Whether for
diagnosis or for treatment the " rapping" is applicable to the pulmo-
nary apices only. It has been studied by Erni10 since 1895.

The Condition of the Blood in Pulmonary Phthisis is the subject of a
study by H. G. Pesel,11 the abstract of which furnishes a useful sum-
mary of the results worked out in this direction in a series of seventy-
five cases, with some reference to previous work. According to the
investigations conducted by John M. Swan,12 on the lines laid down by
Grawitz, it does not appear to be a definite guide to the diagnosis of
phthisis or of its stages.

The Pulse Rate. The prognostic significance of constant quick pulse
is discussed by Stirling.13

The Temperature. A continuous temperature recorder is described
by Donald Ross.14 Coste de La Grave15 writes on the use of the ther-
mometer in diagnosis and treatment.

Rectal Thermometry is shown by the observations of T. N. Kelynack
and Sydney R. Williams16 to be of no definite advantage in the study of

1 Lancet, June 27, 1903.

2 Lancet and British MedicalJournal, May 21, 1904.

3 British Medical Journal, April 2, 1904.
* Ibid., April 11, 1903.

5 Ibid., vol. ii.

6 Beit. z. klin. der Tuber., H. 3.

T Miinchener med. Wochenschrift, 1903, No. 19.

8 D. Medical Wochenschrift, xxix., No. 40.

9 Semaine MeU, March 9, 1904. 10 Ibid.

11 Medical Press, October 28, 1903.

12 Journal of the American Medical Association, March 12, 1904.

13 Miinchener med. Wochenschrift, January 19, 1904.

14 Lancet, February 27, 1904.

15 British Medical Journal, Epitome, November 28, 1903.

16 Ibid., October 24, 1903.

3

34 DISEASES OF THE THORAX AND ITS VISCERA.

phthisis, for sanatorium purposes, oral temperatures arc a sufficient
guide '• when taken during rest."

A higher temperature record in the rectum than in the mouth has
been shown by G. Schroeder and T. Bruehl* to be the rule in the ab-
sence of fever as well as in its presence. They have alsb satisfied them-
selves that the rise in the rectal temperature noted after exercise is not
a pathological but a physiological and local result, probably connected
with the amount of work thrown upon the muscles of the lower ex-
tremity. A much clearer idea of the general temperature is, therefore,
to be gained from observations taken with all due precautions in the
month.

The Behavior of the Body Weight, which is one of the leading factors
in prognosis, has been studied in 1200 cases by Lawrason Brown.2

Spinalgia, as an early symptom, with tenderness of one or more
spinous processes between the second and seventh dorsal, so common,
according to J. Petruschky,3 as to be almost distinctive, is regarded by
him as evidence of bronchial gland implication.

The Tendency to Thrombosis, which is not uncommon particularly at
the latest stages, may lead to the rare condition of blocking of the jugu-
lar veins, witnessed by Charles J. Aldrich.4

THE PLEURA.

Pleural Effusion. The Etiology of Serofibrinous Pleurisy with Refer-
ence to Cytologieal Diagnosis. C. H. BrontingV investigations agree
with the chief conclusions arrived at by Widal and Ravaut, and in
particular with that relating to the prevalence of the mononuclear ele-
ments in tuberculous pleurisy.

Eosinophile Pleural Effusion. W. Barjon and Cade6 find that there
are two kinds : 1. The genuine type, with 10 to 74 per cent, eosino-
phils found in some acute, non-relapsing, non-tuberculous effusions
with mixed formula. 2. The spurious type, with 2 to 5 per cent,
only, which are usually tuberculous.

In a Typhoid Pleuritic Effusion aspirated by Widal and Lemierre7 few
lymphocytes and polynuclear cells were found in addition to large
endothelial flakes. Eberth's bacillus was obtained in pure culture.

1 Sonderabdr. Miinchener med. Wochenschrift, 1902, Nos. 33 and 34.

2 American Medicine, April 25, 1903.

* Miinchener med. Wochenschrift, March 3, 1903.

4 New York and Philadelphia Medical Journal, March 5, 1904.

5 Bulletin Johns Hopkins Hospital, July, 1904.

6 Archiv. G6n. de Med., July 28, 1903.

7 Semaine Medicale, November 25, 1903.

THE PLEURA. 35

Syphilitic Pleurisy with E fusion is described by Frank Jones1 under the
heading of " Syphilis in the Negro." He believes it to be a not infre-
quent event in early syphilis. He also dwells upon the fatality of
phthisis in the negro as probably due to syphilitic infection.

In Tuberculous Pleurisy Hyperchloruria was found in seventeen of
twenty-two cases by Micheleau.2 He regards it as a part of the
" demoralization of the organism" in tuberculosis and as a distinc-
tive sign.

The Upper Edge of a Pleuritic Effusion, when not reaching very high
(7 cm. above nipple), was shown by Damoiseau3 and subsequently by
Garland, always to give rise posteriorly to a curved outline of dulness,
with its convexity upward. F. J. Halls Dally4 contributes a paper
on the radioscopy and radiography of this line, and of pleuritic effusions.
He does not agree with the conclusion previously drawn by Bergonie
and Carriere5 that the convex part corresponds to a congested or
atelectatic area. He refers to the finding of Williams and of Walsham,6
that the lung is often compressed on the inner side of an effusion with a
sickle-shaped edge.

Pus, being denser, throws a denser shadow, and the outline of the ribs
may disappear, while the upper dorsal curve is not so obvious. Change
of level on movement at the upper line, which usually occurs except in
very large effusions, distinguishes the latter from the opacity due to
thickening of the pleura.

Diaphragmatic Pleurisy and its Diagnosis. Richard R. von Stenit-
zer7 lays stress upon three sets of cardinal symptoms: (1) pain and
tenderness ; (2) disturbance of the respiratory mechanism, and (3) in-
spiratory spasm of the upper part of the rectus abdominis (R. Schmidt's
"respiratory abdominal reflex"). The dyspnoea and distress may be
rendered intense by the existence of severe cough, and clonic spasm
and hiccough (Rosenbach) may further aggravate them. There may
also be dysphagia.

The lower thoracic pain has wide irradiations, including that to the
shoulder (perhaps from phrenic impulses reflected down branches of
the fourth cervical nerve). Moreover, a tender spot is found where
the phrenic nerve lies on the scalenus anticus, and another, de Mussy's
" bouton diaphragmatique," near the linea alba at the intersection of
the prolongations of the parasternal line and of that of the axis of the
tenth rib.

1 Journal of the American Medical Association, January 2, 1904, p. 32.

* Revue de Med., xxiii. , Nos. 11 and 12.
8 Arch. Gen. de Med., October 1843.

* Lancet, February 27, 1904. 5 Arch. d'Elec. MeU, July 15, 1896.

* British Medical Journal, July 6, 1901.

7 Wien. klin. Wochenschrift, April 16, 1903.

36 DISEASES OF THE THORAX AND ITS VISCERA.

The respiratory movements of the base of the thorax are much re-
duced, and the paralysis of the diaphragm causes it to assume a high
level, and not to yield any result on examination for Litten's sign.

Louis RenonV eases occurred in association with infarction of the
right lung in heart disease.

The Diagnostic Importance of Abdominal Pain is dwelt upon by
F. II. Edgeworth2 and by dames B. Herrick,3 and in connection with
appendicitis by J. P. Crozier Griffith.'

The Treatment of Effusions. Death or Syncope from Explora-
tory Puncture of the chest is still unexplained. A. E. Russell5 suggests
a reflex causation. Thomas Oliver recalls four fatal cases and discusses
the etiology, which is probably cerebral anaemia. He suggests that
patients should not sit up for the puncture and that brandy should
be given just before.

The Reflex Influence of Puncture is discussed from another aspect by
A. Ricaldoni,6 that of reabsorption of fluid, which he believes may be
due to the stimulation of the serous membrane by a foreign body and to
the molecular disturbance of the fluid.

The Replacement of Pleural Fluid by Aseptic Air, as practised after
Forlanini's method by Antonio Pisani,7 obviates pain, pulmonary
oedema, relapse of effusion, etc. After insufflating air through cotton-
wool slightly treated with formaldehyde he withdraws part of it again
by aspiration at the finish.

This treatment has been practised from time to time unconsciously
by some as the result of leakage, intentionally by others (as by For-
lanini, T. A. Palm, Yaquez and Quiserne, 1902, Achard and Grenet,
1903). By myself it has been repeatedly advocated in connection with
ordinary pleuritic effusions,8 and carried out in connection with chronic
hydrocephalus. James Barr,'' of Liverpool, has recently and almost
simultaneously with Antonio Pisani published his own views and ex-
periences as to its value for the every-day treatment of ordinary pleu-
ritic effusion. He injects the sterilized air by means of the instrument
shown in Fig. 4. This also serves for his intrapleural adrenalin
injections. But, according to Theobald A. Palm,10 it is not requisite
to use any special apparatus ; all that is needed is to clip with artery

Arch. Gen. de Med., June 16, 1903.

Bristol Med.-Chir. Journal, March 1903.

Journal of the American Medical Association, August 29, 1903. * Ibid.

St. Thomas' Hospital Reports, vol. xxxviii.

Revue Med. del Uruguay, Year vi., No. 4.

Gazzetta Med. Ital., March 3, 1904.

Progressive Medicine, 1903, vol iii. p. 36, 37.

British Medical Journal, March 19, 1904.

Ibid., March 26, 1904, p. 759.

THE PLEURA.

37

forceps the tube between the cannula and the aspirator, to remove
the aspirator, place several layers of aseptic gauze over the end of the
tube to act as a filter, and then removing the clip to allow air freely to
enter the pleural cavity, as in a case which he reported in the Edinburgh
Medical Journal for November, 1886.

Fig. 4.

Intrapleural Adrenalin Injections in Serous Effusions. We owe to
James Barr1 the suggestion of this method, from which he has obtained
good results in pleural, pericardial, and peritoneal effusions. Of the
adrenalin solution (1 : 1000) one drachm may be safely injected into
the pleura after removal of the fluid. The results reported by Barr
have been a non-reaccumulation of the fluid in relapsing cases and the
same in fresh cases. Too much adrenalin appears to have been injected
in a case of pericardial effusion, causing temporary collapse, which was
treated with atropine and nitroglycerin injections. The method will,
therefore, need special caution. Barr combines these injections with
injections of aseptic air, which he prefers to oxygen, which might be
too quickly absorbed. He injects half as much air as there has been
fluid withdrawn.

The Treatment by Auto-serum Therapy. G. Donzello2 has employed
with complete success in five cases this method, first tried in animals
by Gilbert, in 1894, and recently with rapid reabsorption of the effu-
sion in nine patients by Tschigaeff.3 Some of the cases were tubercu-
lous and reacted with slight pyrexia, but Donzello's injections of 1.5
to 3 c.c. of the pleuritic serum (of which 5 c.c. only had been with-
drawn) produced no fever, but diuresis only. Under this treatment
recovery took place within two weeks on an average in Tschigaeff's

1 British Medical Journal, March 19, 1904.

s Klin, therap. Wochenschrift, Wien, x., p. 13, 14.

2 Gazzetta d. Osp., 1904.

•>s DISEASES OF THE THORAX AND ITS VISCERA.

cases. He recommends early injection. One of his patients had four
injections, another three, 5 C.C. being removed, and 1 to 2 c.c. injected.
ntinuous Local Applications of Alcohol under a Bandage have been
found efficacious in pleurisy as well as in peritonitis and arthritis by
Soaweljew,1 of Dorpat.

Artificial Pleural Adhesions have been obtained in animals by Karew-
ski and E. linger,2 employing silk ligatures soaked in turpentine— a
proceeding which sounds safely applicable to the human subject.

Empyema. Puisating Empyema. In pulsating empyema as well
as in pulsating pleurisy (four instances of the latter have been recorded
by Lepine,3 Kallmann,4 Alexander McPhedran,6 and others) pulsation
is probably determined by a combination of physical conditions, includ-
ing high t.nsion in the fluid collection and a relaxed tone of the thoracic
parietes, together with a strong cardiac impact. E. Bendix's6 case, in
a woman aged forty-three years, was unusual in its occurrence on the
right side of the chest, for of thirty-eight cases published by Keppler
in 1887, all except three were on the left side. The pulsation, syn-
chronous with the heart beat, was perceptible slightly in the back, but
chiefly in the lateral and anterior thoracic regions. Empyema was
identified by its usual signs, including Barelli's aphonic pectoriloquy,
and after its relief the pulsation gradually subsided, although the
patient was the subject of valvular disease.

Three pulsating tumors in the left mammary region, in the eighth
axillary interspace, and at the lower posterior base, were observed in
F. P. Henry's7 case, which must have been one of pyopneumothorax, as
the mammary tumor gave splash and gurgling, and the chest was reso-
nant anteriorly except at the extreme base, where paracentesis drained
away a large' quantity of offensive pus. Henry has traced only one
other similar instance with three pulsating tumors in an aggregate of
eighty-three cases of pulsating pleurisy.

Treatment by Incision. Leon Brinkmann8 recommends wide
incision in the mid-axillary line, free inspection and exploration (after
gradual evacuation), and a large opening for drainage to be^ obtained
by stitching the pleura (cleared of any periosteum) to the skin. This
is" recommended by its results, recovery having been delayed in only
two out of twenty-seven cases.

1 Allg. med. Ct. Ztg., lxxii., p. 257.

2 Deutsche med. Wochenschrift, May 7, 1903.

3 Lyon Med., February 23, 1896.

* Deutsche med. Wochenschrift, 1901, p. 339.

5 American Medicine, vol. vi., July 1903.

6 Miinchener med. Wochenschrift, May 19, 1903, p. 855.

7 New York Medical Journal, May 9, 1903.

8 American Medicine, February 13, 1904.

THE PLEURA. 39

• Among other papers we mention are those by C. M. Lenhart,1 A.
Primrose,2 P. S. Blaker,3 and John F. Oechsner.*

Simple incision without costal resection is recommended by Coutts5
in very young infants. His own patient was only four months old.

Double Empyema. In dealing with his case Leedham-Green6
departed from the rule that one pleura should be aspirated before
draining the other. Both cavities were opened aud drained, with a
happy result.

Drainage of Empyema. The most noteworthy novelty is the
Samuel Lile7 angular empyema drain. This is found to be safe as
well as comfortable, and allows free irrigation when specially needed.
It is a hard-rubber tube, three-sixteenths of an inch in diameter, and
two inches and a half long, with a cup-shaped funnel on each end, the
cups being five-sixteenths of an inch in diameter (outside measurement).
The tube is bent at an angle a little greater than a right angle, aud
not in the centre, but so as to leave one arm of the angle one inch and

Fig. 5.

Lile's empyema drain.

the other one inch and a half from the angle (Fig. 5). The short
arm is placed in the pleural cavity. On the long arm a flattened sur-
face is made above and below on which the ribs rest ; this prevents it
from turning or becoming misplaced.

Resection of ribs is rendered unnecessary, and patients can sit up in
the open air on the second day. Lile prefers a dorsal incision, which
is stitched up closely around the tube, and can be removed and replaced
almost painlessly every few days.

Van Hook's8 advocacy of continuous aspiration drainage, which was

1 Cincinnati Lancet-Clinic, May 30, 1903.

* Canadian Journal of Medicine and Surgery, August, 1903.

3 British Medical Journal, May 23, 1903.

4 New Orleans Medical and Surgical Journal, August 2, 1903.

5 British Medical Journal, 1904, p. 17. 6 Ibid., January 30, 1904.

7 New York and Philadelphia Medical Journal, July 4, 1903.

8 Journal of the American Medical Association, May 30, 1903.

40 DISEASES OF THE THORAX AND ITS VISCERA.

first employed by Buleau and improved by Perthes, is supported by
the success obtained in two cases; but the simplest methods are those
approved by surgeons. Nevertheless, there arc possibilities of further
improvement in Perthe's original method,1 and Van Hook is enthusi-
astic as to its capabilities.

Continuous Irrigation with Boiled Water was carried out for
a fortnight at my suggestion in a case of severe empyema with chronic
suppurating gangrenous appendicitis operated on by II. S. Pendlebury.
The benefit was partial only, but the patient eventually recovered, the
empyema closing, and the chest re-expanding after seven months' sup-
puration.

The Use of Antiseptics and Sterilized Air. In commenting
upon James Barr's treatment of effusion by replacement by air, Sam-
ways reminds us that Potain injected sterilized air in a case of pyopneumo-
thorax, and that Dieulafoy treated another case by successive partial
tappings of 50 c.c, each followed by an intrapleural injection of solu-
tion of perchloride of mercury.

Remarks on these and analogous methods will be found in Pro-
gressive Medicine, Vol. III., 1903, p. 39.

Pneumothorax. Charles P. Emerson's exhaustive paper in the Johns
Hopkins Hospital Reports, vol. xi., is a most important contribution
wherein are focused the chief data in past records of pathological and
clinical observation and of theory in a series of 358 abstracts, in
addition to original work on the composition of the gas, on the disten-
tion of the affected side, and on pleural cohesion.

The Clinical Forms are discussed by F. Parkes Weber,2 and an
editorial note in the Lancet* deals with its three modes of production
by injury. Bovaird,4 who reports five cases in children, states that
only four children out of eighteen cases collected recovered. J. W.
Trask,5 who gives his experience of nine months at the Fort Stanton
Sanatorium, regards the elevation of 6150 feet as some explanation
for the unusually high percentage of cases and for their fatality, all
excepting one having died.

The Value of Paracentesis, discussed in the Lancet and else-
where, is a question possessing additional interest in connection and in
contrast with the revived recommendation of artificial pneumothorax
for the treatment of pleural effusions.

Oxygen-perflation, with the help of Dieulafoy's aspirator, was
tried by Palmieri,6 of Genoa, 3600 c.c. being used. Though tempo-

1 Beitr. z. klin. Chir., 1895, Bd. xx, H. 1.

2 Zeits. f. Tuber, u. Heistw., Bd. iv., H. 6.

3 December 19, 1903, p. 1742. 4 Arch, of Pediat., November, 1903.

5 Journal of the American Medical Association, March 5, 1904.

6 Semaine MeU, November 11, 1903.

THE LUNQS. 41

rarily improved, the patient died twenty -five days later. The failure of
even daily injections have made it clear to me that one single injection
could not possibly be of any service.

Surgery provides us with the chief if not the only novelty connected
with pneumothorax, in the shape of the " low-air-pressure cabinet," in
which the operators and the body of the patient are contained, while
the patient's head is outside the cabinet, and respiration and anaesthesia
are conducted under normal atmospheric pressure. By this means pul-
monary expansion can be preserved in spite of the pleura being open.

Incarcerated Diaphragmatic Hernia. The difficulty of diagnosing
this hernia before the .T-ray had afforded better facilities, is illustrated
by the fact that out of a large aggregate of 433 cases (Grosser, 1889)
only about twelve have been instances of a correct diagnosis. Dehio's1
case was diagnosed with this help. The patient recoverd from his
iutestinal obstruction, but the hernia remained.

A Primary Endothelioma of the pleura is described by R. Unger,2
and L. Bregman (Warsaw) reports a case of lymphosarcoma invading
the spinal canal.

THE LUNGS.

The Respiratory Mechanism. The Ifeehariism of the Respiratory
Rhythm is regarded by S. J. Kostine3 as based upon the intermittent
action of a medullary centre automatically producing, when freed from
all reflex connections and therefore from all interruptions, a continued
or tetanic contraction of the respiratory muscles. Leaving aside the
action of stimuli reaching this centre from the cranial centres, the inter-
rupting stimuli would b'e mainly conveyed by the vagus from the lung,
the growing inspiratory expansion of the lung causing through the
vagus a growing depression of the automatic convulsive influence, and
at the end of inspiration, when in its turn the stimulation of the pueu-
mogastric would begin to subside, its temporary cessation. Whether
this theory can be made to agree with the experimental results of
others is a matter which physiologists must decide before pathologists
can begin to argue in other terms than those framed by Rosenthal.

Intrinsic Pulmonary Motility. If, as contended by P. Watson
Williams,4 a bronchial contraction accompanies expiration and a bron-
chial dilatation accompanies inspiration (both particularly marked in
children, while in adults the expiratory contraction may be absent during

1 St. Petersburg med. Wochenschrift, 1903, No. 11.

2 Wien. klin. Wochenschrift, 1903, No. 52.

s Roussky Vratch, May 17, 1903; New York and Philadelphia Medical Journal, p. 147.
4 Bristol Med.-Chir. Journal, March, 1903.

42 DISEASES OF THE THORAX AND ITS VISCERA.

quiet breathing), the spasmodio phenomena of bronchitis and of asthma
and the chronic changes in pulmonary emphysema might be explained

as the result of an undue degree and duration of the normal phase of
bronchial dilatation.

.1 Variation in f/n Position of the Margins of the Lungs, independent
of respiration and of any stimuli, is described by Robert D. Rudolf,1
of Toronto, incidentally to observations upon the lung reflex of Abrams.
He is of opinion that the lung is normally " in a state of slow contrac-
tion and relaxation, as are other organs which contain non-striped mus-
cular fibre." Great theoretical importance attaches to this view.
While readily conceiving that every non-striped cell must so long as
life endures be undergoing contractile exercises on its own account,
we must recognize that the systematic and effective contraction of the
whole organ is in many instances intermittent or purposive only, not
strictly periodical. In this case, as also in connection with Abrams'
reflex, we must claim, before subscribing to a belief in the phenomena
stated, full and strict evidence of their genuine independence from the
usual factors, physical and psychical, which in each of us determine
perpetual oscillations in the volume of our pulmonary gaseous contents.

" The Lung Reflex" of Abrams2 has excited much discussion. The
controversy between Auld, Harry Campbell, and Rudolf, although it-
self rather metaphysical in some of its side issues, has partly changed
the " venue " and wandered back into the domain of practical physi-
ology in dealing with the question of the reflex as though it were one
concerned with general respiratory movements of the chest as well as
with the assumed local movement of the lung. The latter, however,
was mainly considered in Abrams' original position. For the present
no agreement has been reached between observers or discussers. Rudolf,
who seems to have given the largest share of attention to the study of
the reflex, is compelled to own that in his experience the phenomenon
is too uncertain to possess definite clinical usefulness — e.g., in early
tuberculosis.

The problem is a physiological one, and it should be investigated
physiologically by physiologists. For instance, the question as to
whether stimulating the skin at a given part does or does not cause the
chest to expand, as a whole, might be settled with considerable accuracy
by combining the methods of registering («) the air traffic in and out
of the lungs by means of an accurate spirometer, and (6) the respira-
tory variations of the cubic measurement of the body as a whole by
immersion in a plethysmograph.

1 Lancet, November 21, 1903, p. 1461.

2 American Medical Journal, January 3, 1903, and Lancet, October 10, 17, 24, 31,
November 21, 23, December 5, 1903, January 2, 1904.

THE LUNGS.

43

The Asymmetry of the Respiratory Movements of the Thorax in Hemi-
plegia led Hughlings Jackson to certain generalizations as to differences
in the nervous mechanism for "the two different services, organic
(respiratory) and animal (voluntary), of the respiratory apparatus."
Tims in a case of left hemiplegia he remarks :

" The greater amplitude of movement of the left upper cage in re-
spiration proper is, I suggest, owing to destruction of some fibres from
the cortex which are for continuous inhibition of the left respiratory
(medulla) centre ; the less amplitude of voluntary expansion of that
left upper cage is, I suppose, owing to destruction of some motor fibres
from the cortex which, evading the respiratory centre, pass direct to
certain left anterior horns, and by these act on the intercostal muscles."1

Judson S. Bury,2 without expressing any views as to their causation,
has been able to verify in 60 per cent, of a large series of cases the
accuracy of Jackson's facts, which I, too, have verified in patients
under my observation. The accompanying tracing (Fig. 6) illustrates
the differences, which Bury describes.

Fig. 6.

Respiratory movements in a case of right hemiplegia: R, right side. L, left side.
A B and A/ b', normal respiration b c and B/ c', force respiration.

On placing the hands in symmetrical positions on the upper part of
the chest the slight excess of movement on the right side during natural
breathing was at once noticed. The movement had more amplitude,
and it began before and came to an end after that on the left side.
AVhen, however, the patient took a deep voluntary breath the excess of
movement was on the left side. These variations affected also the
lateral movements of the chest, as shown by grasping the lower costal
regions.

It may be pointed out that the impairment of muscular tone in the
voluntary muscles of the affected side may be a simple explanation for
the readier and untrammelled action of the. automatically respiring
intercostals during quiet breathing

The Position of the Chest in Dyspnoea, viz., the Position of Inspiration,
is regarded by Harry Campbell3 as due to circulatory necessities. In

1 Lancet, 1895 and 1899, vol. i. p. 79.
3 Clinical Journal, September 9, 1903.

2 Ibid., December 19, 1903.

44 DISEASES OF THE THORAX AND ITS VISCERA.

emphysema augmented action of the inspiratory muscles and "supra-
extraordinary inspiratory distention" are needed (1 ) to stretch the less
elastic fibre, and (2) to open up the pulmonary vessels ; the diaphragm
then carrying on the work of respiration, while the thorax becomes set
and the inspiratory muscles permanently shortened (Campbell). In
order to restrain these developments extreme inspirations (as in over-
exertion, etc.) should be avoided and deep expiration should be practised.

In conclusion Campbell lays down that in no form of lung disease,
not even in the extensive collapse sometimes following the disappear-
ance of a large pleural effusion, are special exercises for the purpose of
bringing about pulmonary expansion, either needful or advisable, because
in all states sufficiently pronounced to cause dyspnoea the organism
expands the lungs just so much as is desirable.

The Physical Methods of Examination. Percussion. H. Engel,1
of Nauheim and Helouan, has tried all the recent methods, including
Reichmann's auscultation rod, von Baas and Hoffmann's tuning-fork,
the methods of visceral resonance and transonance of Benderski and
Runeberg, Aufrecht, and Bueh,2 the adaptation by Smith and Hornung3
of auscultatory friction, and Bazzi Bianchi's discovery ; but he agrees
with Litten, Eggers, Grote, Hoffmann, Lilienstein and others in dis-
trusting them all, but particularly auscultatory friction.

With all our methods the difficulty is the acoustic " Vogelperspektive,"
the internal distance from the surface, which now also tells against our
visual perception in skiascopy; but in the technique of the latter this
difficulty has been overcome ; whereas our acoustic localization method
has not been worked out, although Schott4 introduced the idea of shut-
ting off the lateral vibrations. Tactile vibrations, according to Ebstein,5
are more reliable, in that they help us to determine the " heart resist-
ance."

Engel prefers to trust to sound-waves properly handled, and recognizes
the value of PleschV vertical phalangeal pleximetry, the principle of
which has long been carried out in England in Sansom's small flanged
pleximeter, and he has devised for himself a simple method which
enables him to obtain correct determinations of the heart boundaries.
With his small block-pleximeter (4 cm. high and 1.5 cm. broad), made
of vulcanite, or even of sealing wax, he percusses down the left edge
of the sternum until heart dulness is found, and marks the level ; and
from this the percussions <are carried on with great care, each time cover-

1 Miinchener med. Wochenschrift, September 1, 1903.

2 Deutsche med. Wochenschrift, 1901, No. 38. 3 Berl. klin., April, 1902.

4 Zentralblatt f. d. med. Wiss., 1881, Nos. 23-26.

5 Berl. klin. Wochenschrift, 1904, No. 26.

6 Miinchener med. Wochenschrift, 49th year, No. 14.

THE LUNGS. 45

ing part of the surface identified as dull until clear resonance is obtained.
Each step in this progressive percussion does not amount to much
more than \ cm. The success of this method is due to the precaution
of basing the more difficult determination of the left border of partial
dulness upon the easier determination of its upper border. Engel does
not, however, trust himself to determine the right border of partial
dulness. This want of confidence must strike us as the more surpris-
ing, as the method described by him is sound, and should be efficient
if applied secundum artem and without too much exclusiveness as to
the order of march. Its failure is probably due to the exclusive em-
ployment of " strong, deep percussion."

Immediate Auscultation. The many advantages of this method,
particularly for auscultation of the back, are set forth by Sir Isambard
Owen.1 The most important among them is the easy recognition of
the presence of pleural effusion and its diagnosis from consolidation by
the characteristic tubular breath sound to which it gives rise, but
which the stethoscope often fails to conduct. The wisdom of Owen's
recommendation will be recognized on careful trial.

Phonomyoclonus and the Nature of the Vesicular Murmur.
Walter E. Scott2 claims to have demonstrated in 1898 that the " roaring
in the stethoscope " is due to the conduction by the instrument of the
same muscular sound from the fingers and thumb, which is also per-
ceived when the auditory meatus is closed by the pressure of the finger
instead of by a self-retaining plug. He gives cogent reasons for a view
that the vesicular murmur is partly made up of the muscular sounds
from the inspiratory thoracic muscles. This is a point deserving
systematic investigation.

Meanwhile analogous observations have been made in another direc-
tion by F. Sicuriani3 in four neuropathic subjects. Phonomyoclonus
was first described by Bernabei in 1 903 as a continuous rumbling heard
in the muscles of certain neurotic individuals, even when apparently at
rest. Scott's observations suggest that great care should be exercised
to exclude in all such auscultations the sounds generated by the muscles
of the observer.

Combined " Rigid " and " Flexible " Stethoscopy. The rigid
stethoscope is, in the opinion of experts, the only reliable one. The
problem how to secure its utmost auditory value by using both ears
to it instead of one only had been studied by the present reviewer some
years ago, but in vain. The desired object remains unattained ; but
Heermann,4 of Posen, has now hit upon the happy thought of utilizing

1 Lancet, October 10, 1903. 2 Iowa Medical Journal, July, 1903.

3 Riforma Medica, January 20, 1904, xx., No. 3

4 Deutsche med. Wochenschrift, April 2, 1903, p. 249.

46

DISEASES OF THE THORAX AND ITS VISCERA.

the unemployed oar with a flexible terminal as an offshool from the
chest-piece of the solid stethoscope, as shown in Fig. 7.1 The advan-
tages of this combination of the solid and of the aerial-sound conduction

Fig. 7.

are obvious, though, as with any special instrumental methods, they can
only be obtained after some practice. Heermann finds that sounds are
brought "nearer the ear," as well as better heard, and that extraneous
noises are in a large measure excluded.

Fig. 8.

Aitchison Robertson's Multiple Stethoscope2 is readily under-
stood from Fig. 8. The vibrations collected by the phenendoscope
chest-piece are transmitted to a wide central metal tube A. As many as
ten lateral tubes arise from this tube, each of which can be armed with
a binaural auscultating apparatus. The conduction is excellent, even if
the tubes not in use are not stopped by the plugs attached to the instru-
ment. The multiple stethoscope is invaluable for demonstration to

classes.

Rod-auscultation is not claimed by its inventor, Edward Reich-
mann,3 as a substitute for ordinary percussion; its office is not to test
the density or aeration of organs, but merely their limits as defined by
their investing membranes, as, for instance, the boundaries of the apices

i This stethoscope may be obtained from Boltz, in Posen, and from Pech, in Berlin.
* British Medical Journal. July 11, 1903. s Berliner Klinik., July, 1903.

THE LUNGS. 47

of the lungs. Thus, although it can differentiate even between the
pulmonary lobes, it cannot, as assumed by some, pretend to determine
the several cavities of the heart.

Physical Signs. Physical Examination of the Upper Regions
of the Chest. E. Lloyd Jones'1 conclusions are based upon a
special study of 115 cases and on many additional observations: (1)
"Tilting of the clavicle" is perceptible on the right side in the
majority of adults, but on the left side in the left-handed. Any
departure from this rule suggests some affection of the apex. (2) The
excursion made at the upper chest on deep inspiration is usually greater
on the right. But Ransome finds with the stethometer that in women
it is greater on the left side. Our comment upon these points is that
attitude of the spine and therefore of the clavicle is largely under the
influence of occupation, habit, and nervousness. The same factors,
and in particular nervousness, may considerably affect the symmetry
of movement at different times. This is borne out by the observa-
tions on the respiratory movements in hemiplegia by Hughlings Jack-
son, and more recently by Judson S. Bury.2 I believe that I can throw
more movement into my right or into my left upper chest at will.
(3) Vocal fremitus, more distinct where there is less muscle, is always
greater on the right side, and notably below the right clavicle. Even-
ness of infraclavicular fremitus therefore argues possible increase of
the normal fremitus on the left. (4) As regards percussion, Jones
dwells upon the personal factor and upon some elementary stand-
points in technique, such as the influence of the thickness of the soft
parts, the presence of bone, and of contracting muscles (including the
platysma). The right upper chest is less resonant than the left, except
in left-handed persons. (5) The height of the apices cannot be deter-
mined with accuracy, according to Jones, by percussion. Yet he states,
in sympathy with Eichhorst and with Gee, that they are normally
about level. The inspiratory increase in resonance above the clavicle
he attributes to a general increase of the thoracic resonance rather than
to a rise of the apex, as stated by Reilly. Colbeck finds no inspiratory
expansion and no respiratory increase of resonance, but the reverse ;
his division of the infraclavicular space into a front, middle, and pos-
terior third of diminishing resonance is not recognized by Jones. The
comment upon this part of the paper is that the mobility of the clavicle
and the tenderness of the parts at the floor of the fossa, varying with
subjects and at different times, are serious obstacles to any reliable
results as regards estimation of the height and of the size of the apices.
(6) Auscultation gives at the right apex a harsher inspiratory and ex-

1 British Medical Journal, October 24, 1903. 2 Lancet, December 19, 1903.

48 DISEASES OF THE THORAX AND ITS VISCERA.

piratory sound, particularly above the clavicle, where they may be bron-
chial or even tubular. Gee has also found bronchial breathing some-
times below the right clavicle (especially in women), seldom below the
Left, and often between the scapulas. During quiet breathing an
analogous difference is noted by Jones and by Kidd. Jones points
out that moreover at the left apex expiration becomes inaudible before
the cessation of movement. A knowledge of these points is of diag-
aostic value. (7) Yoeal resonance is best tested by rapidly listening
for it at many points at each side, and estimating the net impression.
It is always greatest at the right apex at and below the clavicle.

An upward movement of the pulmonary apices during inspiration
such as described by A. G. Auld1 is regarded by E. H. Colbeck2 as
impossible, and is strongly doubted by E. Lloyd Jones.3 It is, indeed,
difficult to imagine any adequate mechanism for its production.

Manubrial Dulness. The need for investigation in this direc-
tion may be gathered from H. B. Whitney's "Contribution to the
Study of Manubrial Dulness/"1 and by Albert Abrams' paper on the
" Aortic Reflex," where he claims to percuss out not only the aorta in
its normal condition, but also the pathological variations in its calibre,
as well as those which he finds may be induced by sufficiently strong
concussion of the lower four dorsal vertebra (contraction) or of the
seventh dorsal vertebra (dilatation).

The Intercostal Phonation Phenomenon.5 This is not the
least instructive of Albert Abrams' recent clinical contributions. It
consists in a visible puffing out of the intercostal space when short
words or syllables are uttered. A useful description and an illustration
of Litten's diaphragm phenomenon are included in the same paper.
Abrams finds that coloring the skin yellow, or tightening it over the
ribs by raising a fold between the fingers, intensifies the shadow.

Diseases of the Lungs. " Capillary Bronchitis " and " Bron-
chopneumonia " are two names for one disease. This is urged by
pathologists and clinicians,6 some of whom regard it as contagious,'
just as lobar pneumonia itself. The recognition of this identity is an
essential step toward sound therapeutics. In spite of many important
improvements our treatment remains exceedingly powerless in the worst
cases, as shown by the discussion on C. G. Kerley's paper.8 With
others, he insists upon the value of fresh air.

1 British Medical Journal, October 31, 1903.

2 Ibid., November 7, 1903.
s Ibid., October 24, 1903.

* American Medicine, April 25, 1903. 5 Medical Record, August 8, 1903.

6 "Editorial," New York and Philadelphia Medical Journal, February 13, 1904.

7 J. N. Study, Medical Review, April 11, 1903.

8 Philadelphia Medical Journal, May 16, 1903.

THE L UNGS. 49

The Etiology of Bronchopneumonia is analyzed by Lewis A.
Conner1 chiefly from the bacteriological standpoint. He finds that the
primary cases are almost confined to young children, and that in adults
some of the secondary infections which he enumerates are at work.
G. Rosenthal2 reports three cases of continuous prolonged bronchopneu-
monia which were due to the enterococcus of Thiercelin promptly cured
by removal from the hospital to the open air.

The Treatment of Bronchopneumonia. Inversion with care-
fully aided respiration, as successfully practised by W. B. Allen and
recommended by Southworth,3 is a distinct advance in the treatment
of acute pulmonary oedema of infants supervening in the midst of
apparent health. Judiciously used in a modified way it might also be
of service in the emergencies of acute bronchitis or bronchopneumonia.

Schultz's " Swinging " Method of Artificial Respiration had, indeed,
been previously recommended by C. S. Engel4 from personal experience
in the capillary bronchitis and atelectasis of children, when alternate hot
and cold douches to the chest and to the nape had failed to stimulate
the respiratory centre. The operator is seated with open legs and the
child with its back to him, held at arms' length, hooked up in the axilla
on his index fingers, while the thumb rests on the upper part of the
front of the chest and the other fingers meet over the upper part of the
back. The lower part of the body is swung up and the head down, so
as to face the operator, the entire weight thus coming to be supported
by the operator's thumbs. As the infant is swung back into the first
position the expiratory pressure is relieved, the elevators of the ribs
stretched, and the fall of the abdominal contents tends to draw the
diaphragm into an inspiratory position.

Open Air for the Bronchopneumonia of Pertussis. C. B. Ker5 found
that at the Edinburgh City Hospital the best measures of treatment
(belladonna freely administered, stimulating oils to chest under a jacket
of gamgee tissue, and leeching for cyanosis) still left a mortality of 71
per cent. Open-air treatment, which had been deprecated for the lung
complications, although recognized for the whooping-cough, was resorted
to, except in cases with convulsions. Although the whooping-cough
was undiminished, general improvement began at once, and the mor-
tality (in a series of sixty-three cases thus treated) sank to 31 per cent.
The Pneumoconioses, or Dust Diseases of the Lung, are
specially considered, as well as knife-grinders' phthisis, potters' asthma,
and other " pulmonary diseases due to occupation," in Thomas Oliver's

1 New York and Philadelphia Medical Journal, December 26, 1903.

2 Rev. de MeU, Paris, No. 5. s Arch, of Pediatrics, May, 1903,
* Deutsche med. Wochenschrift, February 20, 1903.

5 Scottish Medical and Surgical Journal, January, 1904,

4

50 DISEASES OF THE THORAX AND ITS VISCERA.

excellent lecture;1 while anthracosis is referred to by Trotter2 and by
T. S. Githens.3

In all of these conditions fibrosis is induced, tending; to destructive
changes in which secondary infections are apt to take an active part.
Special regulations have recently been issued by the Miners' Phthisis
Commission in South Africa1 to mitigate the dangers of gold mining.

Lime-dust Inhalation has, on the other hand, been tried as a treat-
ment for phthisis in eight cases by P. Reckzeh, without any advantage
:ls a set-off for the discomfort, headache, cough, and even nausea occa-
sioned by it.

Acute Fibrous Obliterativb Bronchiolitis, already described
as an occupation disease by A. Frankel/' has been observed by him in
three additional instances,6 as a result of the inhalation of different
kinds of irritating dust, Oxygen inhalations appeared to aid reeovery
in one of the patients ; the other two died after the usual symptoms of
intense dyspnoea and cyanosis with fine rales. Brat also relates a case
due to the inhalation of nitrous fumes. Frankel also refers to the
occurrence of bronchostenosis from compression by calcified glands in
calcosis, as in a case where adhesive pericarditis and erosion of the pul-
monary artery also resulted.

Primary Diphtheritic Bronchitis. In the case related by
L. Sergent and H. Lemaire7 tracheotomy was performed. After
death fibrinous casts were found in the bronchi, continuous with a false
membrane which lined the trachea but did not extend into the larynx.
The Treatment of Chronic Bronchitis. Thomas A. Clay tor8
reviews the practical aids in the direction of hygiene, diet, and medica-
tion ; while the toxic factors (gout, alcohol, renal toxaemia, etc.) must
be recognized, individuals differ, and some tolerate meat much better
than others. "Open air" in chilly climates is not the cure for senile
bronchitis. The dry catarrh of emphysema is often benefited by Dover's
powder with capsicum, or by a matitutinal hot draught of imitation
Eno's water, sodium bicarbonate (15 grains), and chloride (5 grains),
with spirits of chloroform and aniseed water (J. K. Fowler), or by ammo-
nium chloride with bicarbonate and iodide of potassium. Tar in a pill
(2 grains) or in syrup (two parts, with one part syrup of Virginian prune),
or as tar-water, is of much value. For bronchorrhoea the best remedies
are creosote, oil of eucalyptus, and terebene. Sprays of ipecacuanha,
lobelia, tartar emetic, iodide of potassium, etc., may be of use. The

1 Lancet, November 14, 1903. 2 British Medical Journal, May 23, 1903.

3 Philadelphia Medical Journal, May 23, 1903.

4 Lancet, October 24, 1903, p. 1181.

5 Semaine Medicale, 1901, p. 369.

6 Ibid., February 10, 1904. 7 Bull. Soc. Med. des Hopitaux.
» International Clinics, 1893, vol. iv.

THE LUNGS. 51

inhalation of creosote fumes (Arnold Chaplin), salol, Peruvian balsam,
etc., are recommended in fetid bronchitis. No mention is made of intra-
tracheal injections.

Bronchiectasis. In the Etiology of Bronchiectasis Habershon1 recog-
nizes (1) in some cases an idiopathic congenital factor of weakness apart
from any inflammatory agency ; (2) more commonly an inflammatory
origin in bronchitis, pneumonia, pleurisy, tubercle or cancer, and emphy-
sema ; (3) an obstructive causation from foreign body aneurysm, tumor,
syphilitic stenosis, and occasionally adenoid growths. The physical
signs may be nil if the dilatation is deep-seated and not surrounded by
fibrous tissue. They may on the contrary be very extensive, including
inconstant cavernous sounds and the characteristic croaking rale, a long-
drawn sound which has been compared to distant friction, to post-
tussive suction, and to the "veiled puff." The diagnosis needs to be
made most commonly from tuberculous phthisis, from empyema, and
from gangrene or fetid abscess of the lungs. ■

Bronchiectasis in the Tuberculous. S. Edwin Solly's2 case, which he
adduces as contradicting Hoffmann's dictum, in Nothnagel's Encyclo-
paedia, that " as a fundamental principle we may accept the axiom that
tuberculosis may occur as a complication of bronchiectasis, but not the
reverse," may be taken as supporting the experience, not denied by
Hoffmann, that small bronchiectatic areas do occur after circumscribed
processes in the apices where there is a tendency to recovery by sub-
sequent fibrosis.

In MilchnerV patient, who had had haemoptysis, with basic rales, etc.,
pseudotubercle bacilli (not infective to animals) had been found ; at
the autopsy extensive bronchioectasis, but no new tuberculous lesions
were discovered.

Empyema and Bronchiectasis. In the two lectures at the Edinburgh
Royal Infirmary Alexander James4 adduces clinical cases in support of
some important and undeniable propositions : 1 . A large bronchiectatic
cavity, when incised and drained through the chest wall, tends to pro-
duce a pleural cavity, the fibrosed lung being allowed to contract and
separate itself from the parietal pleura. 2. Extensive resection of ribs
is as necessary for the healing of a large bronchiectatic cavity as it is
for an old-standing empyema. 3. If this extensive rib resection is not
performed we must, as time goes on, experience increasing difficulty in
introducing the drainage tube into the lung cavity through the pleural
opening (Fig. 9).

He also contends, on the evidence of clinical cases, that empyema,

1 Clinical Journal, December, 1903. 2 Medical News, October 17, 1903.

3 Berl. klin. Wochenscbrift, July 20, 1903.

4 British Medical Journal, January 2, 1904.

52

DISEASES OF THE Til (WAX AND ITS VISCERA.

especially if fetid, is frequently a cause of bronchiectatic cavities, as well
as of fetid bronehorrhcea. As regards the alleged frequency of this
mechanical process of bronchial dilatation, it must be noted that the
COmmOD observation is, father, how often long-Standing collapse of the
Lung is found post-mortem without any appreciable secondary bron-
chiectasis.

Fig. 9.

The diagrams represent how a large bronchiectatic cavity (B) will tend to contract and
form a pleural cavity (C) as the result of the establishment of drainage through the chest
wall, causing a lessening of its distending forces.

Abscess of the Lung. D. J. Williams mentions in his comments
upon three cases of pulmonary abscess that " most basic abscesses due
to pneumonia perforate downward, and those secondary to abdominal
lesions generally open into the bronchus."1 It would be of practical
interest to know if this personal observation could be widely confirmed.
The diagnosis and treatment are ably discussed by H. Schlesinger,2 of
Vienna, by Karewski3 and by C. Garre and H. Quincke.4

Pulmonary Gangrene should be operated on whenever possible.
This advice is urged by L. L. Mc Arthur,5 as only 29 per cent, of oper-
ated cases have died, while under non-surgical treatment the mortality
is 80 per cent.

Hypertrophic Pulmonary Osteoarthropathy was introduced
for discussion at the Royal Medico-Chirurgical Society of London6 by
E. H. Symes-Thompson, with four cases and two necropsies. The
symmetry and absence of local suppuration suggested toxic action, and

1 British Medical Journal, January 2, 1904, p. 9.

2 Ibid., February 6, 1904.

3 Miinchener med. Wochenschrift, February 6, 1904.
* Grundriss der Lungen Chirurgie, Jena, 1902.

5 International Journal of Surgery, December, 1903.
9 Lancet, Januarv 16, 1904.

TEE L UNOS. 53

it was noteworthy that, like waxy disease, it occurred in syphilis as
well as in chronic suppurations. Percy Kidd gave details of four other
cases. A defective exhalation of volatile toxins hardly seemed to be
an adequate explanation. The analogy with polyarticular rheumatoid
arthritis was obvious. Newton Pitt suggested that possibly protective
marrow changes might be set up by the irritation of the toxins.

Emphysema. Heerfordt's paper1 on the mechanism and symptoms
of emphysema, and F. Smith's paper,2 mainly on its treatment, should
also be mentioned. The latter is in favor of bleeding and of small
doses of digitalis to relieve the heart. He also recommends lateral
compression of the chest by pressing the arms into the sides during
cough.

Glass-blowers' Emphysema is not as frequent as was generally supposed
if Prettin and Liebkind's3 set of observations may be taken as a fair
sample of the entire group. Only five cases occurred among 218 glass-
blowers whom they examined. Fischer4 had previously reported the
absence of emphysema in a series of 500 regimental wind instrument
players.

Surgical Emphysema in the supraclavicular fossa and elsewhere was
the unexpected result of an extraordinary form of treatment reported
by Berard5 by injections of 150 c.c. of air into the perirectal space in
the raphe in front of the sacrum, for the cure of inveterate enuresis.
The patient was cured, but Jaboulay proposes to use artificial serum
in the future instead of air for injection.

The After-history of Tracheotomy is given by W. Pipping6
in sixty-seven of his patients. Only two had developed tuberculosis.

Malarial Affections of the Respiratory Tract have been
observed by L. Sverzhevski.7 He has seen cases of coryza, bronchitis,
cough, and pleurisy which he was able to identify as malarial on the
strength of their immediately yielding to treatment by quinine ; some
of the symptoms he regarded also as distinctive.

Pulmonary Hydatids. A contribution to the clinical history and
to the surgery of this affection is made by J. O'Conner8 from Argen-
tina, which, like Australia, is noted for the prevalence of hydatid
disease.

Most interesting in various respects, and not least in that of its spon-
taneous recovery, is the case by J. Edward Squire and Sydney R, Wil-

1 Hospitalstid, Copenhagen, 1903, Nos. 28, 29.

2 Clinical Journal, November 4, 1903.

3 Miinchener med. Wochenschrift, February 9, 1904.
* Ibid , November 17, 1902.

5 Rev Mens, des Mai. de l'Enf., ixi., No. 5.

6 Zeitschrift f. klin. Med., 1903.

7 Medizine Oboz., November 17, 1903. 8 Lancet, May 23, 1903.

54 DISEASES OF THE TH Oil AX AND ITS VISCERA.

liams.1 The occasional haemoptysis or blood-stained frothy sputum and
the Limited diilness bad led to the suspicion of tuberculous pleurisy, but
the diagnosis was cleared up by the expectoration of typical laminated
membrane.

"COMMON COLDS 7i occupy an important place among the .subjects
discussed in the April number of the New York State Jot/nut/ of Medi-
cine, 1 !•():>. George V. Cott dealing with their symptoms, and A. Alex-
ander Smith with their practical treatment. Their etiology is carefully
studied by .lames J. Walsh.2

The common cold has the following etiological definitions according to
Alexander IIaig.:i " Collaemia (that is, excess of uric acid in the blood)
plus the local action of cold plus a microbe." "You may neglect the
microbe, but you must promptly dissolve out the uric acid," though
both may be attacked together by the inhalation of oil of eucalyptus
and of salicylate of methyl. "To stuff a cold and starve a fever" is
essentially correct. When there is distinct fever salicylate should be
given freely, ordinary diet freely, and no alkali ; but when there is not
any fever give sodium bicarbonate freely, cut off two meals, and after-
ward for twelve hours allow only half the ordinary diet. In both
cases a few hours will suffice to dissolve out the uric acid from the
nose and throat, and the further extension of the cold will be pre-
vented by stopping the solvent and by clearing the blood of uric acid
by the tonic and feeding-up plan (mountain climate action). Haig
regards bronchitis of the aged as a preventable disease from which
those on a correct diet will cease to suffer and to die. But the clear-
ance of uric acid takes time, and from eighteen months to twro years
on a correct diet will be needed to establish a protection from the local
gout of the respiratory membrane.

The Hypochlor klation Treatment immediately cured a slightly albu-
minuric patient of an intense and persistent coryza, which returned
with ordinary alimentation, and was again checked by withholding the
chlorides.4

Iodine Coryza and Iodism Prevented. Fritz Lesser' s5 remedy
is to give the drug little and often, say in a small dose every hour, in
view of the great rapidity of its absorption. When injected under the
skin as iodipin (iodine with sesame oil) there is no iodism, and the
urine may continue to give some iodine reaction for months. As
iodide of potassium is the form in which iodine is always excreted,
and that the thyroid is the only organ in which an albuminous com-

1 Lancet, August 8, 1903. * Medical News, March 14, 1903.

* International Clinics, 1903, vol. ii.

4 Jacquet, Soc. Med. des H6p., February 12, 1904.

5 Berlin, klin. Wochenschrift, November 2, 1903.

THE LUNGS. 55

pound of iodine can be found, it may be more accurate to speak of the
" iodide of potassium toxic symptoms " than of the " iodine symptoms."

Asthma. Etiological^, asthma is classed by James Adam1 among
those affections, including urticaria and perhaps epilepsy, which may
be due to " endogenous toxins "• bred in an overfed muscular system
imperfectly relieved by exercise.

Adenoids in Children are a recognized and curable cause of reflex
asthma, as evidenced in the recovery of E. Y. Stolkind's patients after
operation.2

M. Sihle's3 Pathological Sketch of Asthma includes arterial hypotension
as a determining factor for the bronchial congestion which is associated
with hepatic venous stasis. Variability in individual types inevitably
arises according to the relative share taken by each of the four factors,
which are : (1) tendency to spasm in the bronchi (hypertonic condition
of the bronchial muscles) ; (2) vasomotor insufficiency of the bronchial
vessels; (3) hyperemia of the mucosa of the respiratory tract, and
(4) excessive secretion of mucus.

Hebdomadal Periodicity in Some Cases of Asthma. Asthma is one of
the affections most apt to recur periodically on Sundays or Mondays,
particularly with those who can afford to rest after the week's labors.
It is difficult to eliminate the etiological influence of impression and
habit. But with that reservation J. Adams'4 suggestion is plausible.
Saturday and Sunday may bring with them increased dietetic compli-
cations at the same time as a diminished elimination of any resulting
toxins by exercise.

False Asthma of Gastric Origin. G. Hayem5 gives the long con-
sulting history of a much-doctored but misunderstood case of gastric
distention culminating in suffocation, which was promptly relieved by
the milk and rest cure.

The .Treatment of Asthma has not reaped the full benefit of Brodie
and Dixon's work, previously reported,6 the chief results of which may
be stated again with profit : 1. The muscular innervation of bronchioles,
both for dilatation and for contractions, runs in the vagus. 2. Experi-
mentally, contraction results from peripheral nerve excitation — e. </., of
the sciatic or of the central end of the vagus — or from stimulation of
the nasal mucous membrane at the upper and posterior part of the
septum. Atropine in doses sufficient to annul the effect of these stimuli
would not be safe. Lobelia affords only a temporary relaxation of the

1 British Medical Journal, May 9, 1903.

2 Meclizine Obozron., lix., No. A.

3 Koussky. Arch. Pat. kl. Med. u. Bakt., December 31, 1902.

4 British Medical Journal, May 9, 1903.

5 Bull. Acad, de Med., 1903, lxvii., No. 37. 6 Lancet, October 18, 1902.

56 DISEASES OF THE THORAX AND ITS VISCERA.

spasm. Cocaine locally applied immediately checks the spasms set up by
nasal irritation. It is also suggested that the " blocking " effect upon the
heart of a current passed through the neck might be of use. The spasm
of ursemic dyspnoea is due to asphyxia of the respiratory centre in the
medulla and, according to Brodie, could not result after a previous
section of the vagus.

The Treatment of Asthma by the Direct Route. A strong plea is
entered by Coliu Campbell1 for this method, which he has practised
for nine years in an aggregate of twenty-two cases. The purpose is to
remedy (1) the bronchiolar spasm and (2) the anhydrous state of the
mucous membrane. This he effects by injecting menthol glycerin and
gelatin intratracheal])-, the two latter dissolving the sputum and often
causing its copious discharge, and the menthol reducing the spasm.
The bronchial mucous membrane is very tolerant. Campbell would
not hesitate to inject thirty grains of menthol and two ounces of
glycerin at a single sittiug, though these are extreme doses. He is at a
loss to explain the prolonged relief resulting from the treatment, unless
some germ is either destroyed or expelled. This also applies to hay
asthma; usually the first sitting gives complete relief, while half a
dozen give immunity for the remainder of the season, but not for the
next.

As regards some of the other forms of treatment which have been
recently advocated for asthma, further reports are needed concerning
the hypodermic use of atropine, that of nitrate of silver (five drops of
a 2| per cent, solution) over the vagus in the neck (Bass), and the
cauterization of the septum (Francis). The latter was put forth as one
of very wide efficacy ; but we must be prepared to hear of refractory
cases, particularly among those whose spasm does not yield to the local
use of cocaine.

Methylatropine Bromide, injected by G. Campanella2 in the dose of a
syringeful of a 1 per cent, solution, gave rapid relief to the paroxysms ;
in one case, however, only temporarily, and unpleasant symptoms seem
to have followed in others. Karl F. Kremer3 uses atropine injections
of yi-Q grain at the earliest moment in the attack. It rarely needs to
be repeated more than once in the twenty-four hours. He attributes
to it excellent results, while not foregoing in the treatment the help
of recognized medicinal aud dietetic measures.

Adrenalin Chloride Solution has been injected with great success by
D. M. Kaplan and J. C. M. Bullowa in a number of patients treated
at the Montefiore Home, New York. The internal administration was

1 Liverpool Med.-Chir. Journal, January, 1904.

2 Gazzetta d. Osped., September 20, 1903.

3 New York Med. Monats., December, 1903.

THE LUNGS. 57

not successful, though E. A. Grey1 had good results from internal
treatment by adrenal substance.2

Nervous Coughs and Preventable Coughs. G. Rosenfeld3 dis-
criminates between them, and thinks that too often the term " nervous"
is a libel. Their mode of origin may be very definite and not difficult
to find. The pollen of various plants, or other forms of contamina-
tion of the atmosphere may be the real cause. He has traced coughs
and catarrhs to the irritation from the pollen of trees, and from the dust
from the feathers of a parrot.

Intermittent Respiratory Inflation of the Stomach via a
Tracheoesophageal Fistula. The publication of this remark-
able case of "bellows-action" of the stomach, which was witnessed by
E. Adenst and L. Cadet4 at the laparotomy and found after death to
be due to a cancerous fistula of a peculiar valvular kind between the
oesophagus and the trachea, should lead to analogous cases being noticed.
When the stomach was exposed the inflations were considerable, and
the deflations are stated to have been complete. These alternations in
size coincided with the respiratory rhythm. The severe paroxysms of
cough are attributed by the authors as having some share in the pro-
duction of the condition.

The Therapeutics of Lung Diseases are reviewed by Sir Hugh
Beevor,5 with special reference to bleeding, oxygen, the ice-bag, intra-
tracheal injections, and serotherapy.

Ichthyol is warmly praised by James Burnet6 for its many sided effi-
cacy, and for the good results obtained from it in phthisis. He regards
it as possessing anti-inflammatory properties in addition to the value
of its large percentage of sulphur. Crude petroleum is strongly recom-
mended by A. D. Benkert7 as a safe and most efficacious agent in acute
respiratory affections, as well as in various other affections. His expe-
rience extends over thirty years. Carbonate of creosote has not yielded
to J. A. Scott and Charles M. Montgomery8 the striking results in
pneumonia reported by Wilcox, Van Zandt and others.

The Treatment of Cough is discussed in general terms by FoxwelP
and by Louis Revol10 (stomach cough), and by other writers in connec-
tion with various remedies, such as heroin and glycoheroin,11 ichthyol
and its compounds,12 etc.

1 Semaine Medicale, 1902, p. 144. 2 Ibid., November 11, 1903.

* Berliner klin. Wochenschrift, No. 9. * Lyon MeMical, December 27, 1903.

5 British Medical Journal, January 2, 1904. * Lancet, August 8, 1903.

7 Therapeutic Gazette, December 1.5, 1903. 8 Ibid., December 15, 1903.

» Birmingham Med. Rev., April, 1903. 10 Gaz. des Hop., August 8, 1903.
11 L. Haas and G. de Santos, British Medical Journal, July, 1903.
" De Brun, Therap. Gaz., xxvii., No. 6.

58

DISEASES OF THE THORAX AND ITS VISCERA.

II. MiU!,r's « Solvin," an extractof thymus vulgaris, is reported upon
mosl favorably by Emil Eirsch1 as a remedy for all laryngeal and
bronchial affections, but especially for pertussis, in doses of a tea-
spoonful for children or of a tablespoonful for adults.

Thieucalyptol is the name given by Carl Kussel2 to the following
combination :

R.— Sulph. sublim 85-°

( )1. eucalypti '-®

CarbotiUse 10.0— M.

It is used for continuous dry evaporation at a low temperature, with-
out any production of SO, fumes. This is cheaper than the " sanosin "

Fig. 10.

Campbell's revolving chair.

of Danelius and Sommerfeld, and equally effectual. The powder is
placed on parchment paper in an evaporating dish resting on a piece of
asbestos over a small flame, which the patient learns how to regulate.

Hiccough May be Instantly Cured, in David F. Kelly's experience,
by seating the patient in a chair,3 placing three fingers of each hand on

1 Therap. Monats., February, 1904. 2 Iblfl-

3 New York and Philadelphia Medical Journal, January 23, 1903, p. 185.

THE LUNOS.

59

either side of the larynx and trachea and the thumbs at the back of the
neck, and making pressure on the phrenic and pneumogastric nerves
toward the spiual column.

The Cold Compress to the Chest is extolled by C. Fernet1 for a variety
of affections, including influenza, typhoid, pneumonia, bronchopneu-
monia and pulmonary congestion, incipient haemoptysis and some
cases of tachycardia, particularly the exophthalmic. The action on the
vagus and the vasomotor nerves is probably analogous to that of cuta-
neous faradization. A fresh cold napkin is applied for half a minute
to the same surface after a first application of the same duration. A
different place must then be selected if further applications are needed.

Fig. 11.

Campbell's revolving chair.

The Intratracheal Method has been improved by Colin Campbell2 by
the use of a hydraulic revolving chair worked by pedals, which enables
the physician to incline the patient to the right or to the left imme-
diately after the injection. The speed, as well as the angle, can be
regulated at will (Figs. 10 and 11).

The Technique of Oxygen inhalations is ably set forth by S. Solis
Cohen3 in his papers ou the treatment of senile pneumonia. He also
insists on the futility, if not the danger, of antipyretic medication.

1 Semaine Medicale, xxiii., No. 51.

2 British Medical Journal, December 19, 1903.

s New York and Philadelphia Medical Journal, March 12, 1904.

60 DISEASES OF THE THORAX AND ITS VISCERA.

C. A. Greene's1 experience in the medical uses of oxygen inhalations
lias been most favorable in a variety of conditions. J I is method differs
but in minor particulars from that in common use.

W. Zangmeister* recommends the introduction of oxygen through a
tracheal catheter into the lungs of asphyxiated infants, combined with
gentle expiratory pressure for its expulsion.

A novel cure for sciatica, by subeutaneously injecting oxygen (200
to 2000 e.e.) into the gluteal region, is described by I). Jose Codine
Casteli3 as giving immediate and sometimes permanent alleviation of
pain, and no evil after-effects.

Magnesium Diooside administered internally is regarded by Elias4 as a
valuable source of intraorganic absorption of nascent oxygen, and he
ascribes to the latter the favorable results witnessed. Favorable views
of the same remedy are also expressed by Gilbert and Jomier.5

Liquefied Air is extolled by A. C. White6 as an external application
on the strength of the oxygen which it contains.

Valuable information concerning the therapeutic effects of radium
emanations and rays is contained in papers by D. Turner and J. Mac-
intyre." A practical application of Hughes' ionizer is suggested by
R. Y. Wagner.8 By combining the ionizer with the nebulizer he con-
tends that suspended remedies will be more finely broken up than any
atomizer or nebulizer could achieve.

Respiratory Insufficiency, which G. Rosenthal9 finds so common in
children and in adults, should be treated by adequate respiratory gym-
nastics in childhood. J. V. Troitsky10 and Richard C. Newton11 both
dwell upon the variety of diseases to which children are exposed to
infection by imperfect expansion of the thorax during the period of
growth. Newton insists that deep breathing is essential to good health,
and should be part of every child's education.

THE BLOODVESSELS.

The Aorta. Congenital Stenosis of the Aorta, at the Isthmus. L. M.
Bonnet'2 supplies us with abstracts of published cases of this affection.
The following case illustrates one of the dangers attached to it :

1 New York State Journal of Medicine, November, 1903.

2 Centralbltf. Gynak., September 26, 1903.

3 Rev. de Med. and Chir. Pratique, October 7, 1903.

4 Therap. Gaz., December 19, 1903. 5 Semaine Medicale, March 23, 1904.

6 Medical Record, Jan. 16, 1904. ' British Medical Journal, Dec. 12, 1903.

8 Journal of the American Medical Association, December 12, 1903.

9 Roussky Yratch, September 27, 1903.

10 New York Medical Journal, November 7, 1903.

11 Presse Medicale, February 27, 1904, Nos. 17, 23.

12 Rev. de MeU, March 10, 1903.

THE BLOODVESSELS. 61

Rupture of the Aorta in a boy aged thirteen years, apparently healthy,
is described by Evert Wasastjerna.1 He died suddenly two days after
prolonged skating, which led to symptoms of exhaustion. The pericar-
dium was distended with blood from a rupture at the origin of the
aorta. The ascending portion was largely dilated in connection with a
constriction of the aortic lumen at a spot beyond the descending arch.

Aortitis in its Acute Form is described to us by Bruce-Porter,2 in a
man aged forty -three years, who developed aortic and mitral valvular
defects and cardiac dilatation, but survived for six months under the
influence of morphine.

Two Cases of Rheumatic Aortitis with Dilatation in early life are pub-
lished by Zuber.3 In one of them, that of a boy, aged sixteen years,
who had had seven acute rheumatic attacks, the aortic dilatation gradu-
ally assumed extreme proportions.

The Diagnosis of Aneurysm. Noteworthy papers are those of
Stephen Smith Burt,4 also dealing with treatment, and of P. N.
Drozdovsky,5 who limits himself to the study of Oliver's sign, which
he finds is not capable of differentiating between mediastinal tumors
and aneurysm, or of accurately localizing the latter.

Various papers also deal with the .r-ray diagnosis of aneurysm.

Among the unusual cases may be mentioned that contributed by
Le Boutillier6 in a girl aged nine years (seventeen other juvenile cases
of thoracic aneurysm occurring before the age of twenty years are
collated by him, in addition to abdominal and other cases) ; and that
by A. Sicard,7 in which gelatin injections, "mixed" treatment, and
prolonged compression treatment had all been used.

The Position of the Heart in Aneurysm. Hugh Walsham's8 note on
the transverse position apt to be taken by the heart in aortic aneurysms
calls attention to an important aid to diagnosis well known to experts,
but none the less valuable to all.

In the Treatment of Aneurysm there has been no fresh departure.
"Gelatin " tetanus has occurred in additional cases. As many as twenty-
three have been reported in two years, according to Dieulafoy, who
disapproves the treatment, Guthrie Rankin9 has had four fairly satis-
factory cases of gelatin injections, and Magurie has had seven cases of
improvement against one tetanus death ; but D'Arcy Power and Colt10

1 Zeitscli. f. klin. Med., Bd. 49, Hft. i. bis. 4.

2 British Medical Journal, November 21, 1903.

3 Rev. Mens. d. Mai. del'Enf., xxi., June, 1903.
* American Medicine, February 27, 1904.

5 Koussky Vratch, March 1, 1903.

6 American Journal of the Medical Sciences, May, 1903.

T Presse MSdicale, November 14, 1903. 8 Lancet, May 9, 1903.

9 Lancet, July 11, 1903. I0 Ibid., September 19, 1903.

62 DISEASES OF THE THORAX AND ITS VISCERA.

have met with failure These authors publish an interesting instru-
mental improvement in the method of wiring.

The Electric Treatment or "Brazilian Method" of A. de Freitas1 (by-
positive cutaneous galvanization) is credited by its author with the marked
success obtained by him in eases where iodides and other treatment had
failed. Some cases require prolonged periods of electric treatment.

Congenital Stenosis of the Arterial System. Microsphygmia
(Variot) is the chief manifestation of this rare condition which is apt
to be associated with sexual and other forms of mal-development, and
generally leads to cardiac symptoms with the signs of dilatation and
hypertrophy. These subjects who are specially liable to infections rarely
reach the age of thirty years. Paradis2 has collected and described
twenty cases, with fifteen necropsies.

The Arterial Hypermyotrophy of T. D. Savill is, of course, distinct
from atheroma, and also from arteriosclerosis, of which, however, it
often is an antecedent. Savill3 regards it as one of the main pathologi-
cal conditions upon which cerebral and other hemorrhages depend. At
a later stage degenerative and sclerotic changes supervene in the intima
and in the adventitia. Though usually present, it is not invariably
present in renal disease, and may occur independently of it. To some
of these cases the diagnosis of " chronic Bright's disease " is wrongly
attached, though the kidneys be free from marked changes, simply on
the strength of the increased tension and of senile fibrous changes in
the tissues. This is practically the combination described by Clifford
Allbutt under the term " senile hyperpiesis."

As we speak of myocardial hypertrophy, the condition might be
referred to as myarterial hypertrophy.

Calcification of the Middle Coat of Arteries is found by J. G.
Monckeberg4 to be of rather frequent occurrence in the latter decennial
of life, as an isolated change independent of arteriosclerosis. The
femoral artery shows greater proneness to it than any other.

The Experimental Production of Atheroma in rabbits from long-
continued intravenous injections of adrenalin by Josue5 affords some
support to the view that the affection is due to sustained arterial hyper-
tension, and it also suggests that the suprarenal capsules may possibly
be in some way concerned in the causation of atheroma in man.

The same results have been obtained with adrenalin by Erb
Junior,6 who describes a widely distributed endarteritis and an exten-

1 Brazil Med. Riv. d. J. ; Jour. Am. Med. Assoc, November 21, 1903, xvii., No. 29.

2 These de Lyon, 1902 ; Epitome, Brit. Med. Jour., July 18, 1903.
8 British Medical Journal, February 20, 1904, p. 432.

4 Virchow's Archives, 171, 1. 5 Semaine Medicale, November 25, 1903.

6 XXI. German Congress of Int. Med., Leipzig, April 18-21, 1904.

THE BLOODVESSELS. 63

sive calcification of the aorta, and by Romberg, after the artificial pro-
duction of aortic valvular insufficiency. Marchand, however, contends
that the experimental lesions in question cannot be identified with true
arteriosclerosis, as they are limited to the tunica media, and do not
involve the intima.

Arteriosclerosis. From the wide ranging debate before the Twenty-
first German Congress at Leipzig,1 a few fragments only can be reported
in this section. As to the nature of arteriosclerosis, excluding from its
scope simple hypertrophy of the media and syphilitic disease of middle-
sized and small arteries, our ignorance is emphasized by Marchand's
proposal of a new term, " atherosclerosis " or " scleroatherosis," which
throws into one heap under a single pathological formula such distinct
processes as atheromatous decay and fibroelastic proliferations, the
pathology of which can only be elucidated by further depths of anal-
ysis. Romberg gives us a comprehensive clinical picture of the affec-
tion. His therapeutics may be summed up as " ne quid minis." He
follows neither Huchard nor Rumpf in dietetics, and forbids neither
fluids nor lime salts. The virtues of iodide of potassium are probably
due to its power to diminish the viscosity of the blood cells, and to
modify osmosis, and its good effects are almost limited to the early
stages and symptoms. A gram and a half (22 grains) daily is a suf-
ficient dose. There are no other essentially active medicinal reme-
dies, putting aside those which are symptomatic, except, perhaps, potas-
sium nitrate (Sir Lauder Brunton). Trunecek's serum needs further
testing. Arteriosclerotic nephritis needs cardiac treatment, by small
continuous doses of digitalis or strophanthus, avoiding undue pressure
effects, and in suitable cases by carbonated baths. Other speakers
thought well of nitroglycerin, and were divided on the question of
digitalis and C02 baths. Juvenile arteriosclerosis, attributable mainly
to alcohol and tobacco, was to a certain extent amenable to treatment,
and the prognosis even in later life was not discouraging. F. Hirsch-
feld pointed out that the Gotha insurance statistics mention seventy-one
to ninety years as the period of death from arteriosclerosis, and the same
for gout. Among the symptoms of the affection, Klemperer drew atten-
tion to the frequent occurrence of unexplained and transient febrile
attacks in cases where only slight lesions covered with a slight deposit
of fibrin are found in the aorta after death.

A. Frankel dwelt upon the etiological relations of arteriosclerosis to
infectious diseases, and Hoppe Seyler and Sauerbeck upon the causation
of diabetes from visceral arteriosclerosis affecting the pancreas and
the islands of Langerhans.

1 Semaine Medicate, April 27, 1904.

64 DISEASES OF THE THORAX AND ITS VISCERA.

In his paper upon the early diagnosis of arteriosclerosis which has
attracted attention, Alfreil Stengel1 takes a clinical and practical view
of the whole subject, while M. Allen Starr traces the morbid influence
of vascular disease upon the nervous system. -

Trunecek's Serum. The serum has the following composition:

Sodium sulphate ....... 0.44

Sodium chloride 4.92

Sodium phosphate ....... 0.15

Sodium carbonate ....... 0.21

Sodium sulphate ....... 0.40

Distilled water to 100.00

This is analogous to that of the serum of the blood, minus its phos-
phate of lime and magnesia, and with potassium sulphate added. Tru-
necek injects in the forearm 1 c.c. every few days, gradually increasing
up to 5 or 7 c.c. ; but Levi8 thinks as much as 12 c.c. may be injected.
He also favors an alternation with rectal injections (up to 35 c.c), but
has not given the serum by the mouth. Levi concludes that in cere-
bral arteriosclerosis the serum acts not only on local symptoms but
on others, such as vertigo, disordered sight, ear sounds, headache, and
failure of memory. It is much to be desired that he might support
this view by a stronger array of convincing proofs.

Swithin Chandler4 reports more recently that, according to Alfred
Gordon, Levi has adopted another formula :

Sodium chloride 10.00 grams.

Sodium sulphate 1.00 gram.

Sodium carbonate . . . . . 0.40 "

Sodium phosphate . . . . . 0.30 "

Calcium phosphate,

Magnesium phosphate . . . aa 0.75 "

M. ft. cachets No. xiij.

" Each cachet equals 15 c.c. of serum, or 150 blood serum." Gor-
don has prescribed the serum in capsules. Chandler confines himself
to giving it by the mouth (16 c.c. twice daily) in cases of arterioscle-
rosis, asthma, rheumatism, cerebral circulatory disturbances, tinnitus,
anaemia, and senile fibrosis before operation. " No result was obtained
in some cases, but the proportion of recovery and general improvement
was great " The six cases which he publishes are not convincing.

The Etiology of Intermittent Claudication. Of Erb's 46 addi-
tional cases5 45 were in men, mostly not of the working classes, and
30 were bilateral, and of these, 16 presented no pulse at the foot, while

1 American Medicine, January 2, 1904. ! Medical Eecord, July 4, 1903.

3 International Clinics, 1903, vol. ii.

4 New York and Philadelphia Medical Journal, February 13, 1904.

5 XXI. German Cong. Int. Med., Leipzig, April, 1904; Semaine Me"d., May 4, 1904.

THE BL O OD VESSELS. 65

in the unilateral cases it was absent on the affected side in 13. In the
etiology, which is that of arteriosclerosis, Erb was struck with the
frequency of the influence of tobacco, and recognizes exposure to cold
as an additional factor. H. Idelsohn1 calls attention to the influence
of congenital delicacy of the vascular apparatus as distinct from arterio-
sclerosis, of a racial factor (12 out of 14 of his patients were Hebrews),
of a cold climate — e. g., greater frequency in Finland and Poland — and
also to its frequent association with flat-foot (8 of 14 cases), which may
influence the plantar nerves by direct compression or reflexly.

The Tourniquet in Raynaud's Disease. In the new treatment re-
ported by Harvey dishing,2 of Johns Hopkins Hospital, we have an
illustration of the value of mechanical stimulation as applied to the
vasomotor system.

Obliteration of the Superior Vena Cava. Two remarkable cases
are contributed by Osier3 with important comments on this rare con-
dition. He groups the 29 hitherto recorded cases of complete oblitera-
tion with establishment of collateral circulation as follows: (1) throm-
bosis due to disease within the vein, 10 cases (of these 8 were apparently
simple phlebitis) ; (2) disease outside the veins, 19 cases, viz. : (a) tuber-
culosis, 4 ; (6) mediastinitis, 4 ; (c) aneurysm, 4 ; (d) syphilis, 3 ; (e)
pericarditis, 2 ; (/) carcinoma, 1 ; (g) fibroma, 1.

Life and even health may endure for many years in spite of complete
obliteration of one of the three great veins of the body, and the symp-
toms may ultimately supervene rather acutely ; but in another set of
cases the symptoms may never be quite absent from the first, in spite
of tolerably good health.

A. Meyer4 also reports a case of complete fibrous obstruction of both
vena? cava?, perhaps congenital, in a youth aged eighteen years, who died
with symptoms of cyanosis, general oedema, and lymphatic enlargements.
The dilated vena azygos major was the chief collateral channel of circula-
tion, the superficial veins not being so greatly dilated.

Spontaneous Perforation of the Intrapericardial Portion
of the Inferior Vena Cava in a man aged sixty years, with ather-
omatous aorta, was due to no traceable cause, but is described by I. M. W.
Bourke5 to a simple thinning away of the adventitia and part of the
media with a small central perforation. Two similar erosions occurred :
one in the posterior part of the left pulmonary artery, the other on the
lower part of the left pulmonary vein. No suggestion is offered as to

1 Deutsche Zeitschrift f. Nervenheilk., 1903, xxiv., 3-4.

2 Journal of Nervous and Mental Disease, November, 1902.

* Bulletin Johns Hopkins Hospital, July, 1903, p. 169.

* Medical Record, May 23, 1903.
5 Lancet, March 12, 1904.

5

66 DISEASES OF THE THORAX AND ITS VISCERA.

the etiology, which, perhaps, was fatty degeneration and overstretching

of the vessels.

Phlebitis Migrans. This interesting affection has been identified
by Ernesi Neisser.1 Multiple nodosities occurring in secondary syphilis
in the course of superficial veins had been reported by French writers,
and found to be curable by antisyphilitic treatment, but Neisser was the
first to describe the migration of'the nodules. Tertiary venous gunimata
have been described by Langenbeck, Turner, and Hutchinson as soli-
tary tumors.

Fat Embolism. Fatal after-effects of chloroform in children was
described some years ago by Leonard G. Guthrie,2 and in a recent
paper3 he renews the suggestion that the individual liability is con-
nected with the pre-existence of a fatty condition of the liver, and death
to its aggravations by chloroform and to the resulting escape of ptomaines
and toxins into the circulation, rather than to the occurrence of fat
embolism.

Air Fmbolism. L. P. Wolff4 reviews 115 previous contributions to
this subject, and, as a result of his own experimental investigations, he
offers a novel explanation for the churning heart sounds. Death is due
not to heart failure, but to blocking of the pulmonary capillaries.

Caisson Disease. Gustave Heermann5 adheres strictly to the views
of Heller Mager and Schrotter, who have placed the " gas theory "
upon a thoroughly scientific basis. In order to avoid the dangerous
symptom of "decompression," and in particular Meniere's symptoms,
they recommend that caisson workers should live close to their work
or not leave the neighborhood for some time after stopping work, that
they may resort, if necessary, to the sovereign remedy, " recompres-
sion."

Some of the problems of " caisson sickness " have been experiment-
al^ investigated by Leonard Hill and J. J. R. Macleod :6

1. Compressed air acts equally upon the body fluids at all parts, and
thus does not disturb the circulation mechanically.

2. By strong arc light illumination the occurrence of gas embolism
may be watched ; bubbles may be seen to appear in the capillaries of
the frog at the time of decompression, and may be made to disappear
on restoring compression.

3. The danger and the extent of gas embolism from rapid decom-
pression increase with the duration of the pressure, as the tissues and
juices gradually accumulate the gases dissolve in the blood. At 7

1 Deutsche med. Wochenschrift, September 10, 1903.

3 Lancet, January 27, February 3, 1894. 3 Ibid., July 4, 1903.

* Yirchow's Arch., clxxiv., No. 3. s Volkmann's Sammlnng, No. 334.

6 London Hospital Gazette, April, 1903.

THE BLOODVESSELS. 67

atmospheres the blood contains about 1 1 volumes per cent, of nitrogen,
instead of 1.5 per cent, as normally.

4. Prolonged exposure to 7 atmospheres lessens the C02 output by
oxygen poisoning, and the body temperature is reduced.

5. Pneumonia, convulsions, and paralysis are among the results of
prolonged exposure to high pressure of air or oxygen. The carbonic
acid would liquefy in the lungs at 70 atmospheres, but even 50 atmos-
pheres will cause instant death.

6. Compressed air greatly lessens the evaporation of water from the
body.

In his paper on " Caisson Disease and Divers' Palsy ; an Experimental
Study," discussed before the Academy of Medicine of Cleveland, J. J. R.
Macleod1 referred to the experiments performed in collaboration with
Leonard Hill, which show that animals die either under pressure or
from decompression, and in the latter case from air embolism with
dyspnoea, cyanosis, and convulsions. About an hour is necessary, in
the case of dogs of 10 kilos, to saturate the tissues with gas, and about
the same time to free them of it without the formation of emboli. As
to death under pressure, this was partly due to two co-operating causes
of depression, oxygen poisoning, and excessive loss of body heat from
wet air.

A paper by Charles Aldrich, on " Caisson Disease from the Clinical
Standpoint," was also read and discussed. Much practical experience
was supplied by Frank Roth in connection with the symptoms mani-
fested in the direction of the heart and circulation, of the respiration,
of the nervous system, of the temperature, etc., by the men when
" locked out." No symptoms occurred during the period of com-
pression.

W. T. Howard, Jr., referred to the presence of air emboli recognized
at the autopsies performed on cases of " bends," including bubbles in
the brain and cord, coupled with capillary hemorrhages.

The Prophylactic Treatment urged by Andrew H. Smith2 involves the
establishment of a hospital wherever caisson work is in progress. It
should be provided with a chamber in which a bed could be placed
and into which a tube could convey the compressed air from the
caisson.

Blood Pressure. The study of blood pressure in diagnosis has
been urged by Cook and by J. B. Briggs3 in relation to chronic inter-
stitial nephritis, for the discrimination of myocardial failure from the
varied symptoms dependent upon neurosis, and particularly of true

1 Journal of the American Medical Association, December 19, 1903, p. 1552.

1 Lancet, January 30, 1904. 3 New York Medical Journal, January 31, 1903.

68 DISEASES OF THE THORAX AND ITS VISCERA.

from false angina, and also as a means of identifying unrecognized
differences in the radial pulses in suspected aneurysm.

.1 Sphygmomanometer, described as both simple and easily worked,
has been used by them1 for clinical observations on the relative value
of the various general stimulant measures. One of their conclusions
is of major practical importance: alcohol, they find, is, apart from its
irritant qualities, devoid of any stimulant action upon the circulation.

1'erhaps G. (iaei'tner's new magnifying puh( --controller,'1 while not
aiming at accuracy, may answer the general purpose of indicating the
state of the pulse during the progress of operations.

.1 Musical Pulse-recorder is described and illustrated by Sommer.3
It indicates the pulse variations by changes in the time and in the
pitch of the otherwise continuous tone.

Arterial Hypertension. Among various other contributions to this
subject, a passing mention should be made of Vaquez's paper on satur-
nine, ursemic, and eclamptic high tension and its consequences ; of those
of Laufer and of Ambard and Beaujard4 on the relation of hyperten-
sion to the prodution of cederna and to the retention of chlorides in the
tissues.

Physiologically, blood pressure is found by George Oliver5 to be
influenced chiefly by digestion (rise and fall lasting two and one-half
to four hours), by exercise, and by heat (both producing a fall), and
also by altitude (a fall between 2000 and 3500 feet ; a rise at higher
levels).

The pathological variations are well studied by G. W. Norris" with
the Riva-Rocci apparatus.

H. Richardson7 reports the results of his testing the activity of
various remedies with the help of Hill and Barnard's instrument. He
finds most of the reputed vasodepressors to be at fault, least, however,
the thyroid extract and the Nauheim baths.

S. S. GoldwaterV paper enters into much detail as to the physio-
logical as well as the pathological influences governing the variations
in blood pressure.

The Clinical Aspects of Blood Pressure. 1. General Arte-
rial Pressure. Much has already been written under this heading,
but on the subject of the treatment of hypertension, which is a " fimc-

1 Johns Hopkins Hospital Reports, vol. xi.

' Therap. Monats., xlii., No. 9; Journal of the American Medical Association, 1903,
p 527.

5 Berliner klin. Wochenschrift, 1903, No. 51.

4 Soc. Med. des Hop., Februarys, 12, 19, 1904 ; Semaine MeU, February 10, 17, 1904.
* Lancet, June 13, 1903.

6 American Journal of the Medical Sciences, May, 1903.

7 Medical News, August 22, 1903. 8 Ibid.

THE BL 0 OD VESSELS. 69

tional " long before it becomes an " organic " change, H. Hnchard1
makes, in addition to various recommendations of tried remedies, a
novel suggestion in the direction of serotherapy.

Robins has found that the injection of 1 to 5 c.c. of " Blondel's
lactoserum " (obtained from animals after injections of repeated doses
of milk) determines a marked drop in the capillary tension. He con-
demns carbonated baths in presclerosis and in all " arterial hypertensive
cardiopathies."

He regards overeating as a more frequent cause of arteriosclerosis
than hard drinking.

"( '/ironic Arterial Hypotension " and its treatment are dealt with by
A. Ferrannini.2 He points out that arteriosclerosis may develop as an
indirect result, but that the attendant cardiopathies are not " arterial"
but " arteriovenous " cardiopathies. A leading position is awarded
by Ferrannini to autointoxication in the etiology, and to suprarenal
medication in the treatment of hypotension.

2. Local Arterial Pressure. Visceral Pain and "Vessel-crises.1"
J. Pal3 has supplied a novel and important guide to therapeutics in his
discovery of the vasomotor mechanism of various visceral pains, includ-
ing the visceral crises of tabes, colic, gastralgia, enteralgia, and, per-
haps, angina pectoris. The sympathetic plexuses are the seat of pain,
not the organs. The intestine, for instance, is insensitive, but the con-
traction of its vessels produces extreme overfilling of the mesenteric and
other arteries, with painful pressure effects upon nerves.

Analogous suggestions are presented by William Browning4 for the
relief of pain in tumors of the brain, and by Inglis5 for various forms
of intense pain, as in congestive headache, by the use of vascular de-
pressants.

Blood pressure is probably influenced by gastric distention in a reflex
way, according to Reynier's6 experiments. The arterial depression
induced by distention immediately ceases on evacuation of the gastric
contents. This may have practical bearing upon the treatment of sur-
gical collapse.

Blood Pressure from the Therapeutical Aspect. We are reminded of
the practical observations of J. B. Briggs7 in relation to the comparative
value of drugs. Tincture of capsicum causes a rise of equal height
and duration, as that from whiskey, but without the subsequent fall

1 Bull, del' Acad, de Med., 1903, lxvii., No. 27.

1 Med. Ital., July 20, 31, August 10, 20, 31, 1903.

' Munch, med. Wochenschrift, 1903, vi., No. 49.

* Journal of Nervous and Mental Disease ; Therap. Gazette, 1904, p. 115.

s Physicians and Surgeons, October, 1903.

« Acad, de MeU, November 24, 1903.

7 Johns Hopkins Bulletin, February, 1903.

70 DISEASES OF THE THORAX AND ITS VISCERA.

produced in the case of whiskey by depression of the vasomotor cen-
tre-. Strychnine and digitalin, given subcutaneously, raise the pressure
less quickly, but for a longer time (one to three hours) — longer after
strychnine than after digitalin. Their combination is therefore a most
valuable agent in shock and in toxic states. Subcutaneous injections of
normal saline solution are not found to be true cardiovascular stimu-
lants any more than alcohol, and their uses must be explained from
some other side.

Among the new remedies suggested by Oliver1 ammonium hippurate
and lichenin are stroug vasodilators, the former (in doses of 2 grains)
producing, like Witte's peptone (in the dose of 1 grain), a lasting
effect for twenty-four hours. Ty rosin and especially leuein, which are
vet stronger vasodilators, are, perhaps, contained in the peptone. On
the other hand, glycogen (1 grain tabloid) and levulose (10 grain tabloids)
are both vasotonic and myotonic and likely to suit hypotonic states.

" Hyperchloridation " will need to be studied in its physiological as
well as its clinical effects. W. B. Parsons2 describes symptoms of
dizziness, hallucinations, peculiar brain sensations, loss of memory, etc.,
which resisted abstinence from alcohol and tobacco, but disappeared on
his giving up the excessive use of common salt.

■ Trunecetfs Serum. C. Trunecek's3 own latest explanation of the
remarkable efficacy of the serum injections, observed by him in various
arteriosclerotic, anginal, paretic, dyspnoeic, hypertensive, chronic, alco-
holic, and other affections, is that it probably binds a certain amount
of the C02 in the blood (in the proportion of 2 c.c. C02 to 5 c.c. serum) ;
but the recuperative action in paretic and cardiac conditions of weak-
ness is mysterious.

THE LYMPH CIRCULATION.

The Peripheral Circulation of Tissue Fluid and of Lymph. This
is an entirely new study, the first instalment of which we owe to George
Oliver.4 His conclusions are too important to be omitted:

1. The amount of tissue lymph varies at different times of the day,
and each variation is of short duration. 2. The ingestion of food pro-
duces a rapid flow of lymph into the tissue spaces, acquiring its maxi-
mum an hour after meals, and disappearing slowly. 3. The digestive
curve of variation always follows the same general type, with a rapid
rise, short acme, and a gradual subsidence. 4. As the digestive lymph

1 Loc. cit. 2 Denver Medical Times, October, 1903.

3 Klin, therap. "Wochenschrift, Wien, No. 51.

4 Lancet, October 3, 1903.

THE L YMPH VIE 0ULAT1 ON. 7 1

wave develops there is a rise in the percentages of the corpuscles, of
the haemoglobin, and of the specific gravity of the blood, i. e., the
blood becomes more concentrated. The average rise of the corpuscles
and hemoglobin is 15 per cent, of the specific gravity, 7|°. 5. As the
digestive wave declines there is a corresponding fall in the percentages
of the corpuscle, haemoglobin, and specific gravity of the blood. 6. The
interchange of fluid between the blood and tissues measured : 15 per
cent, of the volume of the plasma flows into the areolar spaces during
the maximum of each lymph wave. 7. There is a complete agreement
between the blood pressure and the exudation of lymph. 8. The rate
of effusion of the lymph is rapid ; fresh lymph is formed in fifteen
seconds. 9. Lymph is disposed of in two ways — by absorption into the
capillaries and by transmission along the lymphatics. 10. The to-and-
fro transfers of fluid from the capillary to the lymph spaces constitute
a circulation sufficient for the requirements of metabolism. This may
be termed the " intermediary circulation." 11. This intermediary cir-
culation provides the mechanism for the supply of pabulum to the tissues
and for the removal of soluble waste products. The lymph wave after
a meal insures the immediate supply of pabulum from the food. Bev-
erages (tea, coffee, and alcohol) act by inciting a flow of lymph into the
tissues. But they fail to restore to the blood the outflow of pabulum
which they create.

This confirms the view that goutiness is primarily due to a retention
of waste products dependent upon a disturbance of the " intermediary
circulation," their removal being prevented either by excessive capillary
blood pressure, or by a diminution of that pressure such as to reduce
the fluid exchange between blood and tissue.

Capillary Blood Pressure thus becomes a valuable source of clinical
information. A subsequent investigation into its behavior after the
ingestion of various constituents of food has enabled Oliver to classify
the latter into groups, some increasing, others decreasing the pressure.
His further results were laid before the Royal College of Physicians
in April, 1004.

These " recent studies on the tissue-lymph circulation m open up
fresh avenues of thought and investigation in some of the darkest
regions of our clinical pathology. Walker Hall's work on The
Purin Bodies of Food-stuffs and the Role of Uric Acid in Health and
Disease, 11)0:3, also contributes much help in the same direction from
a different side. Oliver demonstrates how the lymph flow is initiated
and distributed by " exogenous lymph factors," such as uric acid,
creatin, creatinin, glycogen, and sodium chloride, most of which possess

1 Lancet, April 30, May 8, 1904.

72 DISEASES OF THE THORAX AND ITS VISCERA.

QO nutritive value, but are provided in our food for the purpose of
raising the capillary pressure. Some of them are also generated within
us as " endogenous lymph factors," too often in excessive quantity,
with the evil results well known to clinicians.

All will agree with his conclusion that the study of the circulation
of the lymph, which he has shown to he intermittently effused after the
ingestion of food, during exercise and rest after exercise, and during
sleep, while it loses more or less of that intermittency in many pathologi-
cal conditions, must aid us to control derangements of nutrition and of
metabolism. The " Sharpev Oliver Lectures " should be read in extenso.
The Functions of the Corpuscular Elements in lymph eirculation
have been studied by M. Labbe,1 who finds that while soluble sub-
stances are merely absorbed by the protoplasm of the phagocytes, insol-
uble substances, such as mercury, arsenic, etc., and their salts slowdy
undergo chemical as well as mechanical changes — e. g., calomel being
split up with bichloride and metallic mercury — and in their albuminoid
combinations are no longer reached by the ordinary tests. Owing to
their phagocytic attraction to the site of morbid changes they become
the carriers and distributers of our remedies.

(Edema. The Relative Freedom from Dropsy Observed in the Earlier
Stages of Mitral Stenosis is discussed by James E. H. Sawyer,2 who
endeavors to explain it by the tendency of the affection to hypertrophy
rather than to dilate the left auricle, as the maximum pressure within
the latter occurs not during its diastole (as in mitral insufficiency), but
during its systole. This left auricle hypertrophy would be the chief
factor in maintaining cardiac compensation ; and only after it had begun
to fail would the right auricle and ventricle dilate and dropsy supervene.
Unexplained Dropsies. A case of chronic " idiopathic " general
dropsy is described by R. Staeehlin.3 No disease of heart or kidneys
could be found after death, nor was there any evidence of toxaemia.
The " essential dropsies of childhood," apparently angioneurotic, are
discussed by Arthur W. Fairbanks.4 Exposure to cold seems to be
paramount in the etiology of those cases, and this favors the view that
the nature of the affection is neurotic.

The unusual localizations of acute circumscribed oedema are the sub-
ject of an important paper by H. Quincke and A. Gross5 in continua-
tion of Quincke's earlier paper, in 1882. It is pointed out that the
same process which is witnessed in the skin may affect the deep con-
nective tissues, and may occur in the most varied situations and with

1 Presse Me'dicale, ii., No. 83. 2 Lancet, January 16, 1904.

3 Zeitsch. f. klin. med., xlix., 5-6.

4 American Journal of the Medical Sciences, September, 1903.

5 Deutsche med. Wochenschrift, 1904, xxx., Nos. 1 and 2.

TEE PERICARDIUM. 73

the most varied results, including many symptoms described as rheu-
matic, neurotic, neuromimetic, and even psychic.

Alimentary Dechloridation Treatment ofCEdema has attracted
during the past year greater attention than its pathology, particularly
in connection with the original observations of F. Widal and A. Javal.1
On the relations existing between renal dropsy and the supply of sodium
chloride to the organism a considerable amount of work has already
been done ; but the question is still in an early stage of study, and as it
is a renal question it need not be dealt with at this place ; but an excel-
lent epitome of its history will be found in an editorial in the Journal
of the American Iledical Association for February 6, 1904. As regards
cardiac dropsies, it is proved by the clinical experience already obtained
that the effect of alimentary dechloridation is not the same as in renal
dropsy, and that its adoption in heart disease is not to be indiscrimi-
nately recommended. The most that is claimed for it is that it tends
to avert in cardiac cases the supervention of the severe complications
of dyspnoea, insomnia, vomiting, and albuminuria. It may be well
then to adopt in them a modified plan of dechloridation, or at least to
avoid the administration of large quantities of sodium chloride.

Pulmonary (Edema is best treated, according to Sir Isambard
Owen,2 by venesection, digitalis, oxygen, and particularly subcutaneous
injections of strychnine.

THE PERICARDIUM.

A Localization of the Friction Sound to the precordial area is char-
acteristic of pericarditis, but it is not an invariable rule, as shown in the
two cases by V. Chappet and G. Leclerc.3 The sound seems to have
been extensively conducted by the pleural effusiou and by the adhe-
sions to consolidated lung tissue.

The Normal Flaccidity of the Pericardium and its close adaptation
to the heart are practical facts attested by surgeons, such as Poirier,
Reclus, Potherat, Walther,4 etc., from visual and manual evidence.

The Operation of Cardiolysis, recommended in 1903 by Brauer and
Petersen, has been practised by von Beck,5 of Carlsruhe, in three
patients presenting symptoms of adhesions. These were completely
relieved by the resection of part of the third, fourth, fifth, and sixth
ribs and periosteum. Thus the successful treatment of cardiac adhe-
sions is not beyond the scope of practical surgery, but it is dependent

1 Presse Med., 1903, No. 80. 2 British Medical Journal, January 2, 1904.

3 Lyon MeU, June 14, 21, 1904. * Semaine Medicale, 1903, p. 362 and 369.

5 Ibid., April 3, 1904.

74 DISEASES OF THE THORAX AND ITS VISCERA.

upon a correct diagnosis of their existence. In P. Clemens'1 case the
symptoms of heart failure were attributed to this cause; but Kraske
did oot follow Petersen's example of resecting two of the adherent ribs,
but attempted, though with imperfect success, to ease the circulation by
Talma's operation.

Purulent Pericarditis, and particularly that following pneumonia,
has hitherto been a most fatal disease; but its mortality is likely to be
reduced with an improving surgical technique- and medical treatment.
,1. A. Scott's3 well-studied case of recovery after operation for post-
pneumonic pyoperieardium had interesting features : (a) the absence of
leucocytosis until the pericarditis developed ; (6) the absence of the peri-
cardial friction ; (c) the subnormal temperature in spite of pus in the
pericardium ; (d) the recovery of the patient without the physical signs
of an adhesive pericarditis. J. A. Coutts and R. P. Rowland's4 patient,
aged two and one-half years, had pneumococcus pericarditis and
empyema, and survived nearly four months. The almost universal
fibrinous adhesions concealed an abscess between the heart and lung.
Another case by Coutts" illustrates the difficulties of diagnosis and the
long course (seventeen weeks) taken by the affection when not relieved
surgically. Loculated empyema was diagnosed, but no fluid was ob-
tained by exploration. In spite of radioscopy the diagnosis of pericar-
ditis was not entertained because the apex beat could be plainly felt,
and the heart sounds were clear. The publication of cases such as this
is a most useful reminder of the treacherous latency of pericarditis.

A Caseopurulent Mediastinopericarditis gave rise, in a boy,
to general oedema, the cause of which was judged to be pressure upon
the superior and inferior vense cava?. Looking back upon the case
Lloyd Roberts6 suggests that the sternum might have been trephined ;
whether successfully seems doubtful, from the extent of the fibrous and
caseous infiltration found at the autopsy.

In the Case of Pyopneumopericardium with Left Empyema related by
W. Knowsley Sibley and W. Arbuthnot Lane,7 the classical " water-
wheel " sound was not noted, but the heart sounds had a loud resonating
character resembling the resonance of sounds in a small cave. The boy
died twenty-two days after the pleura and ten days after the pericar-
dium had been opened, from internal hemorrhage, probably due to super-
ficial ulceration of the heart wall. The pericardium had been opened

1 Miinchener med. Wochenschrift, 1903.

4 New York and Philadelphia Medical Journal, January 30, 1904.

* W. Mintz, Centralblatt f. Chir., vol. xxxi., No. 3.
1 British Medical Journal, January 2, 1904.

* Ibid., August 15, 1903. 6 Lancet, November 7, 1903.
7 British Medical Journal, May 23, 1903.

THE HEART. 75

by the tip of the finger laterally, through the bulging pleuropericar-
dium, and was, perhaps, imperfectly drained.

THE HEART.

Heart Examination Methods and Instruments have been keenly
discussed in Germany under the stimulus of the pronouncements of
the so-called School of Marbach. Such men as Ewald and Reichmann
believe in " die gate alte Perkussion" and refuse to admit the possibility
of separately determining the individual boundaries of each of the sec-
tions of the heart. This is also Kaiserliug's1 view, who, however, recog-
nizes the possibility of obtaining by Smith's method the boundaries of
the heart as a whole.

A further adjunct recently added to the method, the Smith-Eeck
(analogous to Reichmann's rod), is mentioned in A. Smith and J. Hoff-
mann's reply to F. Moritz's criticisms.2 It is unnecessary to follow
the details of the discussion as to the value of the phonendoscope in its
varied modes of application and as to the physics of auscultatory fric-
tion. Smith has a difficult position to defend, and he refuses to admit
that Moritz's " orthodiagraphy " is a final test as to the size of the heart.
He suggests that Moritz's failure to recognize greater variations in the
size of the heart may be due to his practice of examining for them in
the recumbent position only. He also regards Moritz's numerical
method of estimation as likely to mislead. In his own hands the
visual method has always confirmed the findings of the acoustic method.

H. Cybulski3 has been using the phonendoscope to his satisfaction
without the lower plate and without the rod attached to it. He reports
that all sounds are better heard by that arrangement, the pulmonary as
well as the cardiac, except any metallic sounds, the soft amphoric breath
sounds of small or deep-seated cavities, and the slighter cardiac mur-
murs. It is obvious, however, that the direct application to the chest
of so large a plate must limit its use.

The Normal Movements and Action of the Heart are studied on
the solid basis of evolution and comparative anatomy by Arthur Keith4
in his fine Hunterian lectures. He shows the negative pressure in the
right auricle to be the work of the early part of the right ventricular
systole, during which the base of the ventricle moves downward toward
the apex (Roy and Adami, 1890, Haycraft, 1891). The stability of
the latter during systole being a law securing that the filling of the

1 Berliner klin. Wochenschrift, 1903, No. 5.

2 Munchener med. Wochenschrift, 1903, No. 50.

1 Therap. Monats. , February, 1904. * Lancet, F'ebruary and March, 1904.

76 DISEASES OF THE THORAX AND ITS VISCERA.

auricles shall be effected by the contraction of the ventricles. He
states that the wave of contraction must pass from the auricular base
to the apex, ami from the apex to the arterial base of the heart. The
secondary negative variation of auricular pressure is slight only (Burton-
Opitz). This may he explained by the return of the ventricular base
t<> its high level as the tricuspid opens. Pathological overdistention
of the right auricle cripples this pumping action of the base, and pushes
the cardiac apex leftward. That of the left auricle tends to push the
heart forward.

In the left auricle he describes the mechanism of occlusion of the
pulmonary vein orifices by the left taenia semicircularis in addition to
their sphincter fibres. Their more efficient closure in mitral stenosis
causes pressure to rise during auricular systole ; their less efficient
closure in mitral incompetence causes the pressure to rise during dias-
tole, when the ventricular wave spreads into the venous system of the
lung, causing diffusion of the murmur. The movements of the left
auricle are dependent for their freedom upon the transverse and the
oblique sinus, which are obliterated in pericardial agglutination. The
aorta has also a share in the events.

The muscular mechanism of the ventricles are also discussed in con-
nection with the heart's action, the fixation of the apex, the function of
the infundibulum and pulmonary valves, and the closure of the inter-
ventricular foramen.

The Abnormal Movements and Displacements of the Heart. The
quasiacrobatic heart performances which some of us have witnessed in
the human subject demonstrate the possibility of changes in the heart's
relations with its surroundings, such as are theoretically almost incred-
ible. There is little doubt that a wide diaphragmatic hernia affords it
the best opportunity for extensive " floating." But being " tethered
short " by its great vessels to the lung and to the liver, to the dia-
phragm, and to the muscular masses of the neck and shoulder, it is
obvious that it cannot do much more than ride at anchor, and that any
distant wanderings could only take place if a " general post " of all
the organs were possible. For the normally built man a barrier is set
to any distant abdominal journeys by the floor of the thorax, beyond
which the heart cannot fall, and through which it cannot drop.

A travelling trunk may be so tightly packed that none of its bulky
contents can stir unless all partake in the movement. Within our body
matters are rendered a little easier by the play of the abdominal parietes
and by the variability in the volumes of the organs, particularly of the
lung and alimentary tube, and be it said by the fact that constant and
regular excursions are normally performed and provided for, which are
well defined in range and in direction for each of the organs. But such

THE HEART. 77

are the connections of the heart that any extensive movement or dis-
placement cannot be carried out without all its attachments being affected
some more, others less, according to the direction of the displacements.
The study of any of the latter is therefore a serious undertaking which
cannot be attempted here.

Cardioptosis is the particular displacement which this year has
attracted the attention of some clinicians, although Arthur K. Stone1
dwells mainly upon the lateral displacements, and E. Barie,2 in his
latest paper, upon those which complicate spinal and thoracic deformi-
ties. His earlier paper3 sums up much of what there is to say about
the physiological and the pathological oscillations of the heart. Albert
Abrams4 admits a " primary essential cardioptosis" in addition to those
varieties which are " voluntary," and to others which, being " associ-
ated " with ptosis of abdominal viscera, may be called " cardioptoses of
accommodation ;" and believes that, although lying low in the thorax,
the dropped heart is couched, with its long axis parallel to the midriff,
and is less influenced than the normal heart by respiration and attitude.
It may produce little subjective disturbance, and is benefited by a
good abdominal support, while the cases " associated " with Glenard's
visceroptosis need the special measures suited for that condition.

Wearing a support is a suggestion contained in Max Einhorn's elabo-
rate figures, although he does not urge it strongly, wisely preferring the
hygienic treatment of the nutrition and of innervation, etc., and the
supine decubitus in sleep, with avoidance of stooping movements. He
insists upon its frequent combination Avith hepatoptosis, and in nearly
one-half the cases with enteroptosis. The heart is not enlarged or dis-
eased. Its dulness varies with its position. The subjective symptoms
include the neurocardiac (palpitation, heart hurry or delay, or irregu-
larity, vertigo, etc.), and there is often inability to lie on the left side.
His investigations of 926 subjects (512 men, 414 women) gave a fre-
quency of 2.37 per cent. (22 cases of cardioptosis, of whom only 4 were
women), that is 3.51 per cent, for males, and of 0.96 per cent, only for
women, whom Einhorn regards as being largely protected by the corset.

A closely allied subject is dealt with by A. Oppenheim5 in his paper
on displacements of the liver and thoracic organs by meteorism. Dw-
tention of the large bowel may affect the position of the heart as well as
that of the stomach ; and as the special displacement of the liver which
it produces is not given by general intestinal inflation the presence of

1 Boston Medical and Surgical Journal, January 14, 1904.

2 Semaine Me"dicale, March 2, 1904.
s Presse Medicale, January 27, 1904.

4 Medical News, August 22, 1903.

5 Berliner klin. Wochenschrift, 1903, No. 42.

78 DISEASES OF THE THORAX AND ITS VISCERA.

liver dulness or its absence assumes importance for diagnosis and for
treatment.

Floating Lira- from increasing bulk and weight, due to the venous
stasis of heart disease, was described by Bruschini. M. I. Sterns1 case
illustrates this result, which is but too well known to heart physicians.
Cherchevsky (1887), however, is credited with having been the first
to observe the so-called " cor mobile " in the healthy subject, with undue
oscillations of the apex beat.

The Cardiac Reflex of Abrams is the subject of a clinical study by
P. Merklen and J. Heitz.2 The reduction in the areas of superficial
and of deep cardiac dulness, which is not obtainable in such cases as
pericardial effusions, or extensive adhesions, or extreme cardiac enlarge-
ment, is, they agree with Abrams, best obtained by stimulation of the
precordium. This reaction is not more strange than that of the vaso-
motor mechanisms in response to various cutaneous or other stimuli.
But, as shown by Heitler, the reaction is to be got from stimulation of
other cutaneous areas, and even by moving the joints. On the pulse
rate the typical effect is a slowing. But in this, as in the matter of
blood-pressure changes, individual conditions and irritability have some
influence. Although the various effects observed are capable of being
worked from the precordium itself, they are also obtainable from other
physical stimuli, and by generalization an easy explanation is arrived
at for the result of such methods of treatment as friction, massage,
counterirritation and others.

The Cardiosplanchnic Phenomenon, Albert Abrams' latest addition
to our physical signs,3 is a transformation of the lower sternal precor-
dial dulness into a resonance, as the posture is changed from the hori-
zontal to the erect. The view that this is due to a reflex from the right
heart into the veins of the splanchnic area is confirmed, he thinks, by
the marked but opposite effect of strong abdominal compression on the
one hand and of the application of a vacuum cup to the abdomen on the
other. Abrams refers to some of the clinical and therapeutical sugges-
tions which arise out of these observations.

The Estimation of the Heart's Functional Fitness is attempted by
Graupner4 on novel lines, by means of comparative blood pressure deter-
minations taken before, and again after, but not immediately after exer-
tion, so that sufficient time is allowed for the subsidence of the incidental
cardiovascular excitement. A depression in the blood pressure would
then indicate relative cardiac inadequacy ; a rise would, on the contrary,

1 Roussky Vratch, August 30, 1903.

2 Bull. Soc. MeU des Hop., July 24, 1903.

s American Journal of the Medical Sciences, January, 1904.
* Berliner Klinik., Heft 174.

THE HEART. 79

represent the favorable effect of exercise on a normal heart. He finds
that the variations in blood pressure are almost parallel with those of
the pulse rate. Normally the pulse rate grows with the dose of work
done, and is lessened by reclining. In disease the reaction to labor is
not so regular, and that to posture may be reversed. Graupner claims
for his method, when carried out with the Zuntz-Bremas ergometer,
that it supplies simultaneously the resistance exercises and the indica-
tions for their use or for their avoidance. On the other hand, it is not
applicable to cases of loss of compensation. Moreover, it is open to the
general objection that no mathematical account can be kept of such
modifying influences as those of psychical and visceral stimuli, and of
variations in the calibre (general or local) of the bloodvessels.

Katzenstein' s Method for Gauging the Functional Efficiency of the heart1
is based upon the fact that the compression of a large artery immediately
determines a rise in blood pressure without any change in the heart
rate, and it consists in observing the state of the pulse and of the
blood pressure before and after compression of both iliacs. While in
strong subjects a rise in arterial pressure of 5 to 15 mm. mercury leads
to no increased frequency, or may even coincide with a slowing of the
pulse even when, as in cases of left ventricle hypertrophy, the rise
may be as much as 15 to 40 mm. ; in others, where the heart may be
considered as inadequate, the pulse rate rises without any increase in
blood pressure, or in some instances with a marked diminution (even
to 30 mm. mercury) in the latter. If Katzenstein could show that
other influences affecting the action and the frequency of the heart can
be excluded, this ingenious method might prove of practical use.

The Value of Murmurs per se in Cardiac Diagnosis is easily over-
rated, as E. G. Wood2 remarks. Take as an instance the whole series
of the so-called " anaemic " heart murmurs discussed by V. F. Orlof-
sky in relation to parasitic pernicious anaemia in Rousshy Vratch, June
7, 1903, the exocardial murmurs, aberrant murmurs, such as those de-
scribed by A. K. Zivert3 in the hepatic region, or again the diastolic
murmurs without lesions of the aortic or pulmonary valves, exhaustively
discussed by R. C. Cabot and E. A. Locke,4 which include cardio-
respiratory and anaemic murmurs, as well as those due to dilatation of
the aorta and aortic ring. Again, undue attention to murmurs may
divert our minds from other important symptoms.

Early Tabes, according to Babinski, Vaquez, and Dufour,5 is some-
times overlooked because a diastolic aortic murmur has been heard and

1 Semaine Med., April 20, 1904. * Southern Practitioner, January, 1904.

3 Koussky Vratch, November 15, 1903.

* Johns Hopkins Hospital Bulletin, May, 1903.

' Semaine M^dicale, 1901, p. 172; 1902, p. 51; 1904, p. 46.

SO DISEASES OF THE THORAX AND ITS VISCERA.

the pupillary signs are misinterpreted as due to the aortic trouble. In
this connection Stahl1 calls especial notice to the frequent association of
cardiovascular changes, and particularly of valvular murmurs with
tabes, and to the probability of their common origin in syphilis.

The Mechanism of Production of Musical Bruits, in other words of
especially vibratile murmurs, is well illustrated by Galli's2 case, where
induration of the heart wall allowed an aberrant muscular fibre to set
up a musical murmur.

Rediip/iratimt of the Scrotal Heart Sound. Readers interested in this
subject may be referred to Cuffer and Bonneau's3 paper and to that of

[J. Gabbi."

The Value of Heart Sounds Heard in the Back, a subject worthy of
clinical attention, has been thoroughly studied by E. Masing,5 whose
paper should be consulted.

The Maximum Dorsal Intensity of a Mitral Murmur is always, accord-
ing to V. Libensky," localized near the lower angle of the left scapula,
and he believes that this intensity bears a close relation to the hori-
zontal extent of the precordial dulness, right heart dilatation throwing
the heart backward. When audible posteriorly aortic murmurs are
more distinct at the right than at the left supraspinous level similar
considerations in connection with dorsal percussion led D. R. Pater-
son7 to define the influence of auricular enlargement as taking effect
upon the precordial more than upon the postcordial dulness, and .dis-
placing the ventricle forward and to the left, results generally admitted
as proved.

The Subject of Presystolic Murmurs and Mitral Stenosis has not made
any advance, nor has it been much handled in literature. Cases are con-
tributed by H. Waldo8 and by James Tyson,0 who dwell upon the asso-
ciation of "tricuspid stenosis and its diagnosis, and sets us the valuable
example of serial and final reporting.

Late Systolic Mitral Murmur*, after careful study, seem to J. W.
Hall10 to be best explained on the assumptiou of an asynchronous ven-
tricular contraction.

Diastolic Murmurs without Lesions of the Aortic or Pulmonary Valves.
This paper, by Richard C. Cabot and Edwin A. Locke,11 is of inrpor-

1 American Medicine, November 14, 1903.

* Deutsche med. Wochenschrift, 1903. s Revue de Med., March 10, 1903.

* Riforma Medica, April 1, 1903.

5 St. Petersburg med. Wochenschrift, May 23, 1903.

« Sbornik klinicky, v. iii. 7 Bristol Med.-Chir. Journal, June, 1903.

8 Lancet, December 5, 1903.

9 Philadelphia Medical Journal, May 23, 1903.

10 American Journal of the Medical Sciences, April, 1903.

11 Johns Hopkins Hospital Bulletin, May, 1903.

THE HEART. 81

tance in the history of an almost new subject. Their conclusions are
of necessity limited, but careful :

1. Dilatation of the aorta, localized or diffused, may be associated
with diastolic murmur.

2. A " cardiorespiratory " diastolic murmur may result from tuber-
culous or other pleuropericardial adhesions.

3. A diastolic murmur, yet unexplainable, may be heard in some
cases of severe anremia (1,000,000 per c.cm. or less).

Diastolic Aortic Murmurs " without Valvular Lesions " are also recorded
by G. A. Gibson.1 Owing to the toughness of the aortic fibrous ring,
temporary dilatation is less likely to occur at this valve than at the pul-
monary. Regurgitation could only be produced by incompetence of the
cusps. And the cases narrated bear out this interpretation rather than
the statement in the title, for the valve flaps were thickened, and there-
fore probably ill adaptable.

Pulmonary Valvular Stenosis and its varieties are thoroughly discussed
by W. L. Ascherson2 in connection with a case where the diagnosis
was not confirmed at the autopsy ; and the same subject is dealt with
by Theodore Fisher3 without any fresh suggestions.

In the Diagnosis of Incompetence of the Pulmonary Valve, E. Fromberg4
draws attention to the hyperglobulia which was present in his two cases,
and which he regards as an effort at compensation. His paper should
be consulted for an account of the other distinctive features of the affec-
tion, the diagnosis of which can sometimes be arrived at only by ex-
clusion.

Cardiopulmonary Murmurs. The relatively greater frequency of
these murmurs in neurasthenics has suggested to James J. Putnam5
that they may be in some way related to alterations in the regulating
mechanism for pulmonary and for vascular tension, and therefore in
some degree under neurotic influence. His contention that their inci-
dence is not adequately explained by a simple mechanism of alternate
pulsatile compression and suction of the alveolar tissue, particularly
when adherent to the pericardium, receives undoubted support from
the circumstance that they are hardly ever heard in vigorous constitu-
tions, even during temporary illness, but with marked frequency in
asthenic male subjects. Should they not be classed among the neuro-
pathic stigmata ?

De Vivo,6 who describes a case of diastolic murmur of this kind,

1 Edinburgh Medical Journal, December, 1903.

2 Lancet, September 26, 1903. 3 Lancet, October 3, 1903,

4 Miinchener med. Wochenscbrift, xli., No. 10.

5 Boston Medical and Surgical Journal, June 25, 1903.

6 Riforma Medica, September 2, 1903.

6

82 DISEASES OF THE THORAX AND ITS VISCERA.

also discusses the mechanism of its production. The necropsy seemed
to justify liis view that a diastolic murmur occurs when the lung is
adherent, as in this case, to the heart, and that it occurs with the sys-
tole when the lung is free. Whether systolic; or diastolic, in time :i
cardiopulmonary murmur must always, lie contends, be an inspiratory
and never an expiratory event.

Venous Murmurs of Unusual Character. A curious murmur is de-
scribed by 1*. K. Pel1 in a man, aged thirty-two years, with a history
of old haemoptosis and slight depression of the right supra- and infra-
clavicular regions, with fine crepitations. The murmur, audible over
tin' entire apex and loudest in the supraspinous fossa, was a continuous
humming, with a whistling overtone and systolic reinforcement. Pel
concludes that both the pulmonary artery and the pulmonary vein must
have been implicated in an arteriovenous aneurysm, or else in a mutual
pressure stenosis.

It may not have occurred to Pel that the vena azygos might have been
the seat of stenosis, as in the interesting case reported by J. Pal,2 that
of a female aged sixty years ; the murmur likewise presented a systolic
reinforcement, was uninfluenced by respiration, and was audible over
the right apex and supraspinous fossa ; but its maximum was opposite
the second and third dorsal vertebra, and it was not conducted over the
jugular or subclavian vein. The site of its production was diagnosed
during life. The patient's tachycardia may have been due to the same
cause (pressure from thickening and fibrous adhesions of the pleura) as
that which led to the venous stenosis and murmur.

The audibility of a fetal heart murmur in exceptional circumstances is
proven by the experience of H. G. Wetherill and J. N. Hall,3 who
diagnosed a congenital pulmonary valve affection.

Frequency of Heart Disease. Physical deterioration, which has
engaged attention in the United Kingdom, might be inferred to exist in
France and Germany, judging from the official reports of an increase4
in the frequency of heart disease among recruits during the last twenty
years (in the proportion of 1.5 to 3.1 per 1000 for Germany and of 1.84
to 2.92 per 1000 for France). Rejections due to heart affections have
also risen in Germany from 9.9 in 1894 to 17.4 in 1898 ; but in France
only from 3.97 to 4.07. But other explanations are suggested, includ-
ing the influenza epidemics and neurasthenia.

Mental Symptoms in Cardiac Disease have been traced by T. D.
Greenlees5 in their varied association with the several forms of valvular

1 Berliner klin. Wochenschrift, April 13, 1903.

2 Zentralblatt f. inn. Med., July 11, 1903.

3 American Journal of Obstetrics, January, 1904.
* Semaine M^dicale, 1903, xxiii., No. 42.

5 Caledon. Med. Journal, April, 1903.

THE HEART. 83

and cardiac affections. A distantly analogous study is that by N. Hirsch-
berg1 on the influence of the mental states upon the circulation and respi-
ration. This influence he finds to be real and characteristic.

Predisposition in Cardiac Inflammations. With Arnone,2 all physi-
cians have wondered at the remarkable individual differences as regards
susceptibility to rheumatic carditis. Perhaps, as he thinks, this may
be a developmental peculiarity and traceable in families as in the in-
stances which he quotes.

Leslie3 believes that all cardiac affections occurring before four years
of age are probably congenital. This seems to him the more probable,
as in children the symptoms of heart disease are less direct and obvious.
He dwells upon the unsatisfactory character of prognosis in them,
owing to their greater liability to dilatation, to pericardial complications,
and to recurring rheumatism. The existence of rheumatic nodules is
regarded as a serious indication.

Congenital Heart Disease. The possibly congenital origin of puerile
cardiopathies in individual cases is often difficult to disprove. L. Con-
cetti4 gives reasons for believing that the majority of them are not ac-
quired, but clue to faulty development, even when occurring in the left
side of the heart. This view is not supported by the experience of
pathologists who examine large numbers of infantile hearts post-mortem.
CasseP found that the defect was certainly acquired in 77 of his series
of 107 cases.

Those interested will find instructive material in the cases reported
by G. Arnheim,6 J. McCowan and H. R. Ferguson,7 and Walter Broad-
bent.8 E. Schreiber's9 case had been diagnosed during life as mitral
stenosis. In Frank E. Tylecote's two cases the diagnosis of mitral
stenosis was correct, but the iuterauricular septum was very defective.
Keith, in his lectures, and G. A. Gibson,"1 in his paper, also touch
upon questions of cardiac development.

Chronic Cyanosis with Hyperglobulia or Polycythemia is now
known to be common in congenital cyanosis, and to this association E.
Fromherz11 contributes six instances. He believes that the principle of
compensation is the best explanation for the red-cell ncrease.

Hereditary Mitral Disease. Is there such a thing ? It would be
rash to deny this possibility, which, after all, is but an extension of the

1 St. Petersburg med. Wochenschrift, 1903, No. 2.

2 Riforma Medica, November 20, 1903.

3 California Medical Journal, April, 1903.

4 Riforma Medica, March 11, 1903. 5 Zeitschriftf. klin. Med., xlviii., 3, 4.

6 Berliner klin. Wochenschrift, July 6, 1903.

7 Lancet, October 3, 1903. 8 Ibid., November 14, 1903.
9 Virchow's Arch., August 1, 1903. ,0 Lancet, December 3, 1903.

11 Miinchener med. Wochenschrift, October 6, 1903.

84 DISEASES OF THE THORAX AND ITS VISCERA.

widely entertained belief in the transmissibility of ;i predisposition to
lnart affections, as well as in thai of a tendency to rheumatism. E. Ilirtz,1
who believes, in spite of Iluchard, as firmly in mitral heredity as most
physicians believe in arterial heredity, and who gives four cases in
support, is satisfied that the valvular affection itself may be inherited,
and may be responsible for some of the cases of " mitral nanism "
of Gilbert and of " infantilism " of Lorrain f in other words, arrested
development, often associated with developmental defects and malfor-
mations, as a result of congenital mitral stenosis. He therefore lays
stress upon the duty of protecting the members of families in which
a mitral affection lias occurred by measures of hygiene, of diet, and
of medication.

If capable of being inherited, then mitral disease should be regarded
as an objection to matrimony ; it should also be the study of early and
continuous treatment.

Etiology of Heart Affections. In connection with the etiology of
heart affections many subjects of interest can only be mentioned as titles
— e. g., " The Predisposing Effect of Excessive Athletic Performances ;"3
"The Cardiac Complications of Influenza;"1 "Cardiovascular Para-
tuberculous Heredodystrophy ; "5 "The Rarer Forms of Cardiac En-
largement ,"'' "Uncomplicated Myocarditis in « the Acute Affections
of Children ;"7 " Acute Dilatation from Maximal Physical Exertion
Not Observed Except after Preliminary Serious Organic Impair-
ment;"8 " Heart Failure in Toxsemia Conditions, Beri-beri and Diph-
theria Par Excellence."9

" Mitral Pseudoinsufficiency," as represented to us by Ferrannini,10
is not a subject which could be profitably discussed in a few lines.

The Mechanism of Dilatation consists, according to E. H. Colbeck,"
of a gradual loss of muscular tonus. As the latter is governed by the
nervous system, cardiac dilatation may be influenced for better or for
worse by a great variety of factors. Among the latter Alexander
Morison12 gives prominence to the neural factor, which may operate
mainly from the centre, including the mental and the psychical spheres,
or at the general or visceral periphery.

1 Presse Med., September 19, 1903. 2 Ibid.

3 Albu and Caspari, Deutsch. med. Wochenschrift, xxix., 14.

4 E. G. Wood, American Medicine, October 17, 1903.

5 £. Mosnif, Revue de Med., 1903.

6 Hale White, British Medical Journal, October 24, 1903.

7 Carpenter, Lancet, May 30, 1903.

8 De la Camp, Zeitschrift f. klin. Med., 1904, Nos. 1 and 2.

9 Arthur Stanley, British Medical Journal, December 26, 1903.

10 Clinical Medicine, August, 1903; Epit., British Med. Journal, January 23, 1904.

11 Lancet, April 9, 1904. 12 Edinburgh Med. Journal, March, 1904.

THE HEART. 85

On the other hand, James Mackenzie,1 on the strength of Hering's
demonstration that a rising ventricular pressure can produce premature
contraction of the ventricle, apart from its nervous connections, believes
that in some cases of delirium cordis the dilatation is secondary to the
irregularity, and that the primary cause is not a disordered nerve regu-
lation, but an undue irritability of the heart muscle, causing the ven-
tricle to take on the inception of the cardiac rhythm which belongs to
the great veins.

Compensatory Hypertrophy is believed by G. A. Gibson- to be,
both in the heart and in the bloodvessels, part of nature's plan of cure,
and to be accompanied by hyperplasia. This is also why graduated
exercise is advocated as part of the general treatment of cardiac disease
by Stephen Smith Burt,3 N. S. Davis,4 and many others.

Ulcerative Endocarditis should always be kept in mind in obscure
clinical cases. As it is apt to be insidious and latent, the possi-
bility is not negatived, sometimes even by sterile blood cultures, by
absence of murmur, and by a normal temperature. C. FazioJ refers to
atypical cases of this sort in recording his own acute case, which was
fatal in six weeks without any fever. In Henry M. Fisher's6 case
(perhaps due to the gonococcus, but no blood culture was made) the
pulmonary valve was attacked and the ventricular septum perforated,
in addition to gangrene of the nose and ears, renal infarcts, etc. ; yet
there was never any pyrexia.

Gonococem Endocarditis Maligna was diagnosed by 0. J. Hafhegger7
in a well-studied case, although the blood proved sterile before and
after death. A " benignant " form is also described by Rosenthal."

Pneumococeus Endocarditis, a complication estimated at a percentage
of 0.2 in cases of pneumonia, was combined in I. Y. SakhatskyV case
with pericarditis, and involved extensively all the valves. It was
recognized three days after the crisis instead of, as usual, rather later.
It has been pointed out that this variety often attacks the pulmonary
and the aortic valves, rather than the mitral.

Endocarditis Sometimes Belated to Typhoid and Paratyphoid Infections
may also, according to Henry L. Eisner,10 be looked for in direct or
indirect association with appendicitis.

' British Medical Journal, March 5, 1904.

2 Adaptation and Compensation, British Medical Journal and Lancet, October 17,
1903.

3 Medical News, March 19, 1901.

1 Journal of the American Medical Association, November 14, 1903.

■' Gazzettad. Osped., 1903, xxiv., No. 29.

6 New York and Philadelphia Medical Journal, May 30, 1903. ' Ibid.

8 Journal of Experimental Medicine, 1899, iv.

9 Ronssky Vratch, October 4, 1903. 10 Medical News, May 9, 1903.

86 DISEASES OF THE THORAX AND ITS VISCERA.

Streptococcus Endocarditis is illustrated by Gordon MoirV case, in
which aneurysm of the peroneal artery developed after the suppura-
tion of a hydatid.

Micrococcus Rheumaticus Endocarditis Maligna is generally preceded
by a rheumatic history. This was the case in 53 per cent, of males
and 71 per cent, of females among T. R. Glynn's cases. Post-mortem
evidence of chronic heart disease was obtained in 83 per cent, of his
patients, including 8.4 per cent, congenital cases. Glynn's lectures
and S. Blum's two papers on the etiology of endocarditis should be
consulted.

Traumatic Endocarditis. The antecedent valvular lesion which
Orth regards as a sine <ji'<i mm seems to have been traumatic in Can-
neyV interesting case of roaring systolic murmur of seventeen years'
duration. The traumatism was a transfixion of the chest by a foil at
the third left intercartilaginous space.

The Late Effects of Typhoid Fever on the Heart and Bloodves-
sels deserve greater clinical attention than they have hitherto received.
It is in the nature of things that prolonged immobilization and slow con-
valescence should protect the heart ; but in spite of these helps to pre-
ventive as well as curative treatment by rest, appreciable damage remains
in a proportion of cases. W. S. Thayer has examined the question in
a series of 183 cases. The details must be read in the original, but
the general conclusions point to the importance of typhoid fever as an
etiological factor in cardiac and vascular disease, and to the duty of
keeping a close watch upon the cardiovascular system during the fever
and after.

Heart Syphilis is too large a subject for adequate treatment in these
pages, but I. Adler4 calls attention to many of its aspects and to the
necessitv for its earlv recognition and treatment. Leonard Weber' had
previously covered the same ground, and M. M. Breitmann had dealt
with it exhaustively in Gazette des Hdpitaux, February 21, 1903.

Cardiac Complications in Dysentery. Dysentery gives rise to
toxic heart complications, such as enlargement, tachycardia, weakness
or dilatation, murmurs, etc., according to Nenniuger,'1 in 29.7 per cent,
of cases. He calls attention to the importance of noting the cardiac
condition.

The Infective Nature of the Rheumatic Endocarditis of childhood
is the theme of F. G. Poynton's lecture.7 In 150 fatal cases there was

1 Lancet, October 10, 1903. 2 American Medicine, June 6, 1903.

3 American Journal of the Medical Sciences, March, 1904

4 Medical Record, February 20, 1904. 5 Ibid., August 29, 1903.
B Arch. f. Schiffs. u. Tropen Hyg., November, 1903.

7 International Clinics, 1903, vol. ii.

THE HEART. 87

damage to the mitral in 149, damage to the aortic in 51, and damage
to the tricuspid in 36. This is explained by the greater complication
of its capillary blood supply conveying to it more abundantly the diplo-
cocci, which, he thinks, travel through the coronary circulation. Poyn-
ton insists that rheumatic fever causes a dilatation of the heart, and that
this can be demonstrated by percussion. " The early clinical evidence
of rheumatic heart disease is often myocardial, rather than endocardial."
Valvulitis may exist, however, with or without the dilatation, and
Poynton thinks he has traced its early onset, both in the mitral and in
the aortic valves in previously dilated hearts. When to a persistent
mitral murmur is added a persistent reduplication of the second sound
at the impulse, the reduplication " points to a thickening of the mitral
segments, and is of the nature of a presystolic murmur." The disap-
pearance of a cardiac murmur is often a spontaneous result, and cannot
prove the efficacy of any form of treatment. Sometimes it is only tem-
porary, as the preliminary disappearance of a systolic murmur before
the advent of a presystolic murmur (Stephen Mackenzie).

Thomas E. Satterthwaite's remarks in the same volume, on the
" Etiology and Diagnosis of Valvular Affections," will also be read
with profit, as well as Louis Eaugere Bishop's suggestion as to the
" Peripheral Causes of Heart Disease."

The Clinical Evidences of Myocardial Damage in Rheu-
matic Fever are discussed by E. J. Poynton in his second lecture.1
Rheumatic myocarditis runs the risk of being overlooked for want of
early physical signs. In its full development with dilatation it was
recognized by Sir William Gull in 1870, and later by James Goodhart,
Samuel West, David B. Dees, and A. E. Sansom, who speak of the
"swollen heart " of rheumatism. Poynton and Payne were able to
show, in 1898,2 that dilatation might occur, as a result of the rheumatic
poison and independently of any pericarditis or endocarditis. Since
then they have traced the presence of the diplococcus, which must be
held responsible, if microscopic appearances and inoculation experi-
ments have any meaning. In practice they contend that cardiac dilata-
tion is more often the cause of an increased cardiac dulness than peri-
cardial effusion, and they dwell upon some of the differential features
in the diagnosis between them. The recovery from deep lesions such
as obtain can only be slow, and treatment must be protracted and
Largely made up of rest and of support. Poynton wisely deprecates
the exaggerated fear of animal food in the rheumatic cachexia or con-
valescence of children, and he also thinks that the rest treatment might
be overdone.

1 International Clinics, 1903, vol. iii., p. 220.

2 Transactions of tlie Royal Medico-Chirurgical Society.

88 DISEASES OF THE THORAX AND ITS VISCERA.

The Latest Pathology of the cardiac and other lesions of rheumatic
fever is summed up by F. J. Poynton1 in his lecture on " The Par-
allelism Between the Clinical Symptoms and the Pathological Lesions of
Rheumatic Fever." All malignant endocarditis is not necessarily rheu-
matic, and mixed infection is one plausible cause ; but he contends
•• that the diploeoeeus is of itself capable of producing the condition of
malignant endocarditis single handed, and that some of these cases are
the direct result of the rheumatic infection." The dormant diplococcus
may have been roused to virulence, like the bacillus in tuberculous
glands. Just as in rheumatic pericarditis, varieties and degrees may
also be traced between the extreme types of healing endocarditis and
of malignant endocarditis. The intermediate or borderland case is one
in which after three months, perhaps, of refractory symptoms the
necropsy shows no pericarditis, but much dilatation and myocarditis,
and not very large vegetations on the mitral, a condition comparable
to the virulent form of pericarditis. The variety ending in mitral
stenosis is comparable to the pericarditis with external and internal
adhesions, the smouldering process persisting, but not virulent, and as in-
sidious as subacute arthritis. Poynton remarks that advanced stenosis
is rare in childhood or before twelve, though there might have been time
for its production in cases of early rheumatism, beginning at four or
five years of age. Early adult life is the time when it is common.
Though not suggesting that all cases of rheumatoid arthritis are due to
rheumatic fever, Poynton states tl that rheumatic fever may be a cause
of intractable arthritis affecting the periarticular tissues, and even the
cartilage and bone, and that it may be accompanied with much mus-
cular atrophy." As there may be different degrees of virulence, so
there may be different poisons. It does not follow that arthritis is
" rheumatoid " or " septic " because it is refractory. There is no proof
that an arthritis which does not react to salicylates is not rheumatic.

The great cause of chorea is rheumatic fever ; there may, perhaps,
be other causes. Chorea probably resembles tuberculous meningitis in
affecting the meninges, but it is rarely fatal. In estimating the rheu-
matic nature of cases it should be borne in mind ' ' that when the
rheumatic infection obstinately attacks one system it often spares the
others," and there are also advanced cases of mitral stenosis, just as of
obstinate chorea, with no history of rheumatism.

Rupture of the Left Auricle is so rare that Foott and De H. Hall's2
report deserves to be noted. Their case was a stoker whose left
ventricle was dilated and hypertrophied, and the mitral orifice stretched.
No valvular defect is reported to have been present.

' International Clinics, 1903, vol. iv. p. 95. ' Lancet, January 1(>, 1904.

THE HEART. 89

Perforation of the Heart by a Gastric Ulcer. In this case per-
foration occurred through the walls of the left ventricle close to the
left corner of the mitral valve. This is so rare an accident that it is
well it should have been put on record.1

Angina Pectoris. ColbeeJc's Theory of Anginal Pain as noted in my
last year's report attributes the distress to the result of systolic stretch-
ing of assumed interspersed areas of degenerated myocardium, a reversal
of the normal mechanism of systolic contraction, which may well be felt
as incompatible with life. Sudden death might be explained by the
resulting disarrangements in the central medullary mechanism, or else
by the extension of the degeneration over Kronecker's centre in the
interventricular septum. According to this theory the cases of " angina
sine dolore " would present so much degeneration as to suppress suscep-
tibility to pain, and the other varieties known as " pseudoangina "
would be regarded by Colbeck as due to vasomotor ataxia setting up
sudden pressures and pain within the myocardium, just as this may also
occur incidentally in the course of severe angina. The inefficient
struggle against increased arterial pressure and the pain are in the
older men, according to Lauder Brnnton, identified with the entire
heart, rather than with portions only.

Angina Pectoris in Mitral Stenosis. In Nothnagel's series of
1500 cases of valvular disease only one presented this association.
Graham SteelP reports two cases of heart pain, with mitral stenosis, but
without systolic murmur, and refers to other cases in young women
which it would be difficult not to describe as cases of angina, though
presumably the coronary arteries may not have been implicated in them.
These cases furnish him with interesting suggestions as to "referred
visceral pain " and " direct sensitiveness of the viscera." Although
it has been stated that in cases of presystolic murmur, without systolic
murmur pain is not usually present, there was implication of the sen-
sory areas associated respectively (a) with the transverse portion of the
arch (the inferior laryngeal segment), and (b) with the ascending por-
tion, the first, second, third, and the fourth dorsal segment, and perhaps,
also, the third and fourth cervical segments, the second and third dorsal
segments also influencing the supraorbital headache ; (c) the auricle was
represented in the fifth, sixth, seventh, and eighth segmental distribu-
tions. This referred pain was to be expected, while that referred to
the aortic segments needs explanation. The author alludes to the obser-
vations of J. Ross, of J. Mackenzie, and of H. Head on referred pain.

Infective Angina Pectoris is the name given by J. Pawinski3 to
cases occurring after acute infections (influenza, tonsillitis, etc.) in which

1 Norsk. Mag. f. Laeg., 1903, p. 185. a Lancet, November 21, 1903.

s Bull, de l'Acad. de M&L 1903, lxvii., No 35.

j)0 brS EASES OF t&E THOHAX AND ITS VISCERA

heart innervation is affected by the toxins. Endarterial changes may
sometimes follow, giving rise to true coronary angina. This latter view
was that subsequently suggested by llnehard.1

11 BILIARY A.NGINA PECTORIS" is another form of possibly infective
trouble which Gilbert and 1'. Lereboullet2 regard as common.

On the Clinical Abnormalities of Rhythm, and in Particular on
Bradycardia much has been written. General views of this subject
are presented to us by Roland G. Curtin,8 Bassoe,4 and with great
thoroughness by William Osier.'

The Etiology of Bradycardia.6 The condition may be physio-
logical, as in R. J. Blackham's case, or it may occur in the young
from toxaemia, as in BurziV case, aged sixteen years, occurring after
measles. More commonly it is due to structural lesions affecting the
nutrition or the function of the myocardium or of the nervous system
of the heart. In H. Silbergleit's cases" the affection was "cardial,"
rather than "vagal,11 because atropine did not avail to accelerate the
pulse. Osier's fourteen cases include the chief varieties of the con-
dition.

L. E. Norfleet's9 extreme case ran down to a minimum ratio of 8 or
!> per minute. This was a "Stokes-Adams" case with convulsions
limited to the head and neck. Small hypodermic doses of morphine
did the most good. P. Kidd's10 patient, a female aged fifty-six years, had
epileptiform fits, with a pulse of 25 to 28 per minute. She improved
under thyroid extract and nitroglycerin. A. Zeri11 records a remark-
able case of perfect synchronism between heart beat and respiration.

Thomas E. Satterthwaite's12 paper contributes much information to
some of the less distinct aspects of the subject of -the infrequent pulse ;
but, as with tachycardia, the nature of the condition remains unexplained.

There is first the great distinction between the physiological and the
pathological slowness of heart. The first group contains not only the
congenital or inherited variety, but that also which may occur in preg-
nancy. Slow action is part of the order of things in certain individuals,
and is not to be acquired. The pathological or anginal slowness is in
its etiology most various, but occurs under two distinct types, the par-
oxysmal and the continuous or chronic ; the latter, being associated
with vascular disease, is less common and more unfavorable. The

1 Semaine Medicate, November 11, 190:;. 2 Ibid., p. 370.

3 American Medicine, August 1, 1903.

4 New York Medical Journal, September 5, 1903.

5 Lancet, August 22, 1903, ,; Ibid.

7 Gazzetta d. Osped., October 4, 1903.

8 Zeitsch. f. klin. Med., xlvii., 1, 2.

9 Medical Record, November 21, 1903. 10 Lancet, February 13, 1904.

ii lOC- cjt. u Medical Record, January 31, 1903.

THE HEART. 91

paroxysmal variety has different degrees of gravity. An important
group is that regarded by Satterthwaite as connected with gastro-
intestinal irritations, and reminds us of the similar etiology of some
paroxysmal tachycardias. Another strong analogy is brought out by the
results of treatment. Remedies addressed to the abnormal rhythm are
not ouly useless as correctives, but apt to do harm. It is the causa
causans that we should endeavor to treat. The pathological slowness
of heart is, I believe, to be regarded as an evidence of weakness rather
than of strength, both in the chronic variety and in the paroxysmal,
and the foundation for all treatment in both forms seems to be rest
rather than stimulation. As insisted by Satterthwaite, alcoholic over-
stimulation is the worst form of accelerator treatment in these cases.

Arhythmia. Traumatic Arhythmia from direct irritation of
the ventricular wall is illustrated by the case of O. Riethus' patient,1
in whom a bullet dropped into the heart after lodging for three weeks
in the parietes. Its tossing about, visible by the arrays, set up violent
arhythmia, which lasted six months, but completely ceased when the
bullet became stationary. Experiments on dogs confirming these data
add further interest to the communication.

Continuous Irregularity of the Heart. The cause of con-
tinuous irregularity of action is referred by James Mackenzie, of Burnley,2
to the inception of the rhythm of the heart by the ventricle, instead of
by the venous ostia at the entrance of the left auricle. The existence
of this change in movement is proved, according to Mackenzie, by
the peculiarities shown by the tracings of the jugular pulse. When the
heart acts irregularly the auricular wave in the venous pulse does not
precede the ventricular systole, as shown even in tracings with slow
acting heart. "When the ventricle takes on the inception of the
rhythm the heart is always irregular." In the other case, " where the
auricles or venous ostia give the start, it is always irregular." An
exception is made to this rule, for the very rapid action of paroxysmal
tachycardia, which is regular, though regarded by Mackenzie as due to
ventricular precession.

The occasional extra systole is an isolated occurrence of the same thing.
The fault consists in a premature stimulus production in the ventricle,
with an inverted conduction of the stimulus, under the influence of
abnormal irritability and excitations of the heart's muscle itself rather
than of its nerves. A good instance is that of irregularity lasting for
hours after some violent and unwonted exertion. As dilatation and
inefficiency are present in the permanently continuous cases, we might

1 Deutsche Zeitschr. f. Chir., 1903, xlvii.

2 British Medical Journal, March 5, 1904.

92 DISEASES OF THE THORAX AND ITS VISCERA.

have been inclined to identify the existing- cause or excitation for the
irregularity with the dilatation itself. But Mackenzie is convinced
from a study of the clinical facts and appearances before and after the
onset of disturbance that it is the irregularity which produces the dila-
tation and inefficiency.

The treatment should be directed to lessen the irritabily and avoid
the excitations. Opium and the bromides are of service ; " but no
remedy equals prolonged rest in bed."

An able editorial criticism in the British Medical Journal for March
">, L904, ]). 5603 points out the element of uncertainty in too rigid an
interpretation of pulse tracings ; while the assumption that an auricle
may be so much distended as not to be able to contract upon its con-
tents, and thus initiate the ventricular contraction by " Gaskell's
bridge," does not receive any support from the demonstrable experi-
mental results of distention paralysis of the auricle, the auricle fibres
remaining, even then, able to propagate a stimulus to the ventricle.

The Clinical Analysis of Arhythmia has also received a valu-
able contribution. K. F. Wenckebach1 recognized by clinical observa-
tion the correctness not only of the myogenic theory of the normal
heart's action, but likewise that of Engelmann's experiments and con-
clusions, much of which, it may be said incidentally, was based upon the
work done in England by Gaskell and his school as to the fourfold
endowment of the muscular fibre with (1) contractility, (2) excitability,
(3) conducting, and (4) originating power for rhythmic stimuli, each
of these functions being separately liable to disturbance. In the nor-
mal state they are all four suspended during systole, and again active
during diastole. If now the conducting power be alone depressed, it
may not succeed in transmitting all the auricular stimuli to the
ventricle ; say every fourth may be blocked out. But this extra rest
will restore the strict rhythm for the next series of beats ; this is
attorhythmia due to blocked ventricular conduction. If the block should
occur at "Gaskell's bridge," arching from auricle to ventricle, the
auricular beat may be normal, but there may be bradycardia and
arhythmia of the ventricle. Similar explanations obtain with regard
to the disturbances of the other functions. In pulsus alter nans one
systole is so great as to leave the contractility of the ventricle equal to
a smaller and shorter effort only, and this occurs early because of an
increased irritability of the fibre. As regards the pulsus bigeminus, it
is still uncertain whether it is not, as Wenckebach believes, sometimes
the act of the entire heart, and not merely due to a superadded extra-
systole of the ventricle. The physiological fact that a local stimulus

1 Philos. Trans., 1882-83.

THE HEART. 93

may give rise to an extra contraction of the ventricle irrespective of
any conducted auricular or nervous impulse is nevertheless of funda-
mental importance in the clinical pathology of arhythmia, and, prob-
ably, also of tachycardia itself.

Pulsus Bigeminus and Hemisystole. A case of double heart beat
and apex beat is describe! by K. Doll1 in a ursemic patient with cardiac
hypertrophy and dilatation. He attributes the bigeminal action to the
influence of digitalis in this and in other analogous cases.

Hemisystolism — i. e.} a synchronism of the right and of the left ven-
tricular systole was brought up again for discussion by E. von Leyden,2
who since 1868 has been a believer in the possibility of this mode of
heart action under the influence of large doses of digitalis. The
challenge has been taken up by H. E. Hering,3 who refers to the evi-
dence of actual inspection of the heart's action in animals as a proof
that hemisystolism is impossible, except in the act of dying, when a con-
dition may set in which he designates as "post-mortal hemisystolism."
That which v. Leyden describes is, in his opinion, a " pseudohemisys-
tolism," being really a form of bigeminal beat. " Bigemination simu-
lating hemisystolism " is also the conclusion arrived at by F. Riegel in
his important article.4 A secondary systole is hurried along in the midst
of the diastolic time; every other systole and diastole being thus ren-
dered uneven and unlike, whereby an impression of hemisystolism
might easily be conveyed to the observer. Experiments have long
ago shown that digitalis is an efficient cause of bigeminal action.

Pulsus Paradoxus. Three types are described by F. Riegel.'5
They are respectively due to direct compression as in fibromediastinitis,
etc. (Kussmaul) ; to inspiratory obstructions as in laryngeal croup, such
as to greatly heighten intrathoracic inspiratory suction ; and lastly, to
cardiac inadequacy as in the failing heart of emphysema, where the
peculiarity of pulse may disappear with the administration of digitalis.

The Diagnosis of Nervous Arhythmia. E. Rehfisch6 intro-
duced a new method of estimating the nervous or the cardial nature of
arhythmia in any given case. Absolute identity in the time and dura-
tion of the phases of each of a series of pulse waves is quite exceptional
in the healthy. Out of one hundred sound subjects only four presented
absolute regularity; but the "difference" which existed between the
duration of two successive pulse waves in the remaining majority, and
which Rehfisch adopts as the normal difference, was under 20 per cent.

' Berliner klin. Wochenschrift, March 9, 1903.

2 Deutsche med. Wochenschrift, xxix., No. 21.

3 Ibid., xxix., No. 22. * Ibid., October 29, 1903.

5 Deutsche med. Wochenschrift, May 14, 1903.

6 Ibid., xxx., Nos. 11, 12.

94 DISEASES OF THE THORAX AND rTS VISCERA.

This never exceeds ."> 1 per cent, in health, but in organic disease it
may run up as high as L20 per cent., and in addition there is then more
or less irregularity. Seeing this in neurasthenia and other nervous
conditions, as well as in direct or reflex irritation of the vagus, the per-
centage of difference does not surpass 40, and, as the difference is
usually due to the occurrence of extra-systoles rather than to an essen-
tial irregularity, he regards this method as capable of demonstrating
whether arhythmia is due to nervous or to cardial causes.

Other Functional Affections of the heart are dealt with in
papers, or are illustrated by cases, by various authors, including
A. Amantini,1 J. G. Edgren,2 Frank P. Norbury,3 and others.

Stokes-Adams Disease,4 or rather symptom-group, known by the
names of the discoverer and of its chief exponent, consists, according
to Osier, ' of (1) a profound disturbance in the automatic mechanism of
the heart — true bradycardia, hemisystole, and allorhythmia ; (2) ner-
vous symptoms — vertigo, syncope or convulsions ; and (3) secondary
symptoms — Cheyne-Stokes breathing, angina pectoris and the like.

Its etiological factors may be (1) physiological, as in its relative fre-
quency in the dark races and in old age; (2) neurotic: (a) organic, as
in diseases of the brain, cord, or nerves, and (6) functional, as in melan-
cholia, hypochrondriasis, and neurasthenia; (3) toxic: (a) inorganic
poisons, such as lead ; (b) bacterial poisons, as in typhoid fever ; (c)
vegetable poisons, such as digitalis, and (d) metabolic poisons, as in
uraemia, jaundice, etc. ; (4) cardiac and cardiovascular with definite
lesions, as in a large majority of the cases of bradycardia.

The clinical groups are therefore the post -febrile, the neurotic, and
the arteriosclerotic ; and Osier further distinguishes between severe cases,
senile cases, and cases of slow pulse with occasional syncopal attacks
in younger healthy men.

The chief types are the syncopal and the convulsive and pseudo-
apoplectic. Among the cardiovascular features he draws attention to
the true and the false bradycardia, to the " heart block," or independent
auricular systole, to the " heart arrest," seen also in some cases of angina
pectoris and analogous to the effects of Kronecker's puncture, and to
the general visceral vasomotor events. The nervous features include
vertigo, syncope, pseudoapoplexy, and epileptic seizures.

The pathology may be chiefly cardiac, as urged by Bassoe,6 or as
Huchard holds, connected with local vascular changes in the medulla.
Death occurs suddenly, but often not early in the cases, some of which

1 Gazzettad. Ospedale, 1903, xxiv., No. 119. 2 Hygeia, Stockholm, No. 1.

3 Interstate Journal, St. Louis, April, 1903.

4 Adams, Dublin Hospital Reports, 1827 ; Stokes, Dublin Quarterly Journal of Medi-
cal Sciences, 1846.

5 Lancet, August 22, 1903. 6 Loc. cit.

THE HEART. 95

show temporary improvement. Hygienic methods and careful living are
the essentials of treatment, and recourse may be had in suitable cases to
iodide of potassium and the nitrites. The epileptiform and pseudo-
apoplectic seizures may sometimes be warded off by posture.

Tachycardia. The Frequent Pulse and its Causes are practically
reviewed by Thomas E. Satterth waite, l together with palpitation and
abnormal rhythm. The mechanism of the higher rates of tachycardia
is difficult to explain in the light of experimental physiology, which
shows that lesions of the pneumogastric may give a rate of 150 to 180,
and the irritation of the accelerator fibres of the sympathetic a rate of
120, unless we fall back upon the theory of " interpolated " beats or of
premature pulses " (Gushing, Mackenzie). This is based by Hoffmann
upon his observation of superadded beats arising in the auricle of
frogs from electric stimulation of the venous ostia. Leaving aside the
long list of pathological conditions causing frequency of pulse, Satter-
th waite dwells upon the tachycardias due to toxic causes, to reflex
causes, and to neuroses (Graves' disease, hysteria, epilepsy, neuras-
thenia). He describes three varieties: the temporary, the par-
oxysmal, and the permanent. Extreme figures recorded are 308 for
the rate (Bristowe), ten years of age for early occurrence (Broadbent),
and eleven years for the duration (Bristowe). As the range of possible
existing causes is a very wide one, and the condition is not a disease
but a symptom, the treatment cannot be laid down apart from the indi-
vidual case, and we find that the most varied remedies sometimes answer,
though a common experience is the uniform failure of medication.

Paroxysmal Tachycardia is regarded by H. Frick2 as a depressed
activity or quasiparalysis of the medullary heart-retarding centres.
Pressure on the right vagus, whether applied by the finger, by deep
breathing, or by Valsalva's experiment often succeeds in arousing
the lethargic centres to renewed activity, and to the propagation of
retarding impulses down the left vagus. Hoffmann's additional cases
of " herzjagen "3 include an instance beginning at nine years of age.
Hoffmann refers to compression of the vagus, to deep breathing, or
holding the breath, and to lying or squatting down, as occasionally suc-
cessful in aborting the attacks.

A structural lesion had apparently not been described prior to that
presented by H. Schlesinger's4 patient, who had suffered from typical
attacks and died suddenly. The vagus was compressed by tuberculous
glands and showed chronic changes in its fibres.

1 International Clinics, 1903, vol. iv.

2 Wien. klin. Rundschau, 1903, xvii., No. 26.

3 Deutsche Arch. f. klin. Med., lxxviii., Nos. 1 and 2.
* Seraaine M<?dicale, December 23, 1903.

96 DISEASES OF THE THORAX AND ITS VISCERA.

Paroxysmal Tachycardia of Epileptic Causation. G. Bellisari1 1ms
studied four cases, and refers to seven other observations which support his
contention. One of Ins patients had had epileptic seizures, the second epi-
lepsy and asthma, the third was a highly nervous woman, not an epileptic.
In the fourth, a young man who had recovered from embolic hemiplegia
and aphasia, recurrent epileptic attacks set in, accompanied by tachy-
cardia Lasting about an hour and yielding to bromide. Bromide was
also administered to the other patients with benefit, Attention is
railed to the marked coincidence between the heart attacks and the
epileptic attacks, and to the fact that after the tendency to fits had
been subdued by bromide, the aura still occurred, followed by the
heart attacks. This form of paroxysmal tachycardia is, according to
G. Bellisari. due to suspension of the cardioinhibitory function of the
vagus from various kinds of cortical irritation, and influenced by bro-
mides. Permanent hyposystole may result in some cases.

The tachycardia of early tuberculous infection is a suggestive theme.
F. Vialarge2 points out that it is at first dissociated from any tempera-
ture reaction, and from any arhythmia, and that it must be regarded
not as a cardiac affection to be treated by heart drugs, but as evidence
that the circulatory centres are the earliest to be influenced by the toxin,
and as a guide to diagnosis and to the direct treatment of tuberculosis.
Treatment of Heart Disease. Prevention is the first in importance,
but comes last in our practical cardiology. Our present teaching^ and
action may be summed up in the avoidance of the various infections,
and especially of rheumatism ; but even this is a perplexing task.
With J. Porter Parkinson3 I realize how little else seems to be said
and done. This is also the theme of Robert H. Babcock's address at
Memphis, October 7, 1903. As a definite contribution to the subject
he recommends the removal of all chronically diseased tonsils in all
those who have once suffered an inflammatory rheumatic attack.

General Directions on well-known lines are laid down by various
writers— e. g., Stephen Smith Burt4 as one of the most recent— who
reviews the drug treatment as well as the general management, includ-
ing rest and the more delicate subject of exercise. N. S. Davis,0 Jr.,
of Chicago, writes a useful paper, in which he upholds the value of
resistance movements judiciously employed.

Abdominal Massage has been studied by Alfred Neumann and Fritz
Frick,8 with special reference to its effect upon the pulse, respiration,

1 Riforraa Medica, March 11, 1903.

2 Bull. G4n. de Therap., lxxii., 8.

3 The Hospital, October 3, 1903. 4 Medical News, March 19, 1904.

5 Journal of the American Medical Association, November 14, 1903.

6 Therap. Monats., December, 1903, p. 611 (with bibliography.)

THE HEART. 97

blood pressure, and general symptoms. They have no evil results to
report. Although no great impression was made upon the pulse and
blood pressure, many patients declared themselves much the better
for the treatment, and the conclusion may be drawn that this may often
be of service.

Altitude in Chronic Heart Affections is not, according to
Hoessli,1 a source of any risk before the age of thirty to thirty -five
years any more than for other chronic ailments. All that is needed
by cardiopathy according to Regnard, is to become acclimatized to the
altitude. Babcock,2 for whom the question is partly one of blood press-
ure, is impressed with the fact that the heart-invalid is at a relative
advantage over the unrestricted healthy person whose heart may easily
be overtaxed by reason of his consenting to remain inactive.

On the other hand, T. Zangger3 has a note of warning on the danger
of mountain railroad trips, especially for the aged, in whom the result-
ing heart failure or apoplexy may not occur until days after their return
from the trip.

The Nauheim Treatment. " Beneke" and Schotfs Treatment is
again presented to us by various writers, including C. C. Thorne4 and
Paul C. Franze.5 The latter claims that the influence of the chlorides
(sodium, lithium, and calcium) and of the carbonic acid, the propor-
tion of which is artificially regulated so as to give (1) thermal baths ;
(2) thermal-sprudel baths, and (3) effervescence-sprudel baths on the
cutaneous vessels and nerves is capable of raising low blood pressures
and of lowering high blood pressures, while giving to the heart the
mildest form of exercise. Glover Lyon6 attributes some of the effect
to the atmospheric depression of the place, and Colbeck to the cuta-
neous action of the water heat of the gas bubbles rather than of the salt.
An economical non-corrosive homely installation for the simple car-
bonated bath is suggested by M. Cloetta.7 A solution of NaHP04 is
conveyed to the bottom of the water in the bath, and a corresponding
amount NaHCO, powder is dusted over the surface, which, slowly dis-
solving, sets up an effervescence throughout the water. Cloetta intro-
duces the solution from a clipped fountain syringe hanging over the
bath, the tube terminating in distributing branches easily arranged by
means of " T " pieces.

The " heart cure" advocated by Homer Wakefield,8 with a promise
of a 50 percent, reduction of mortality, includes CG2 baths, but is not

1 Tberap. Monats., February, 1904.

2 New York Medical Journal, August 8, 1903.

3 Correspb. f. Schw. Aerzte, 1903. * Lancet, July 18, 1903.
5 British Medical Journal, April 9, 1904. fi Ibid.

1 Correspb. f. Schw. Aerzte, 1903, xli., No. 14.
8 Medical News, November 21, 1903.

98 DTSEASES OF THE THORAX AND ITS VISCERA.

limited to them. His extensive treatment aims (1) a1 oxidizing away
evil principles (by oxygen inhalations, iron, and enemas of 50 to 100
per cent, of a saturated solution of sodium bicarbonate with or without
hydrogen peroxide) ; (2) at relieving the vascular system by portal and

renal remedies, and by restoring oxidation (a teaspoonful of hydrogen
peroxide solution every three hours may change anuria into diuresis
within twenty-four hours), and (3) at strengthening the heart by ergot,
adrenalin, glycerophosphates, phosphorated oil, etc., and by mechanical
methods.

DIET occupies often a still greater place than in that of most other
diseases. Fluids in particular have to be judiciously managed, and
restrictions are variously prescribed. For instance, Kraus1 favors tem-
porary and periodical reduction in the accustomed amounts, say a
reduction from 1500 c.c. down to 1200 or 1000 c.c. per diem. This
is valuable in early or slight cardiac inadequacy.

The Treatment of Heart Failure. Good remedies are few and
quickly told. Strychnine, digitalis, and adrenalin are Eisner's three
remedies for heart toxajmia in pneumonia.2 Adrenalin is also praised
by Eisendraht3 among other resuscitants. Alexander Morison4 is the
advocate of " boldness " in treating cardiac failure with large and
repeated doses of digitalis, alone or with strophanthus. At the medical
society's debate Sir Douglas Powell5 and others emphasized much good
advice, including attention to the stomach, and in pneumonia avoidance
of overfeeding. The value of strychnine, and of venesection whenever
indicated, was generally recognized.

Cardiac Stimulants are classified by O. T. Osborne6 in the follow-
ing order of efficiency : alcohol, camphor, amyl nitrite, nitroglycerin,
ether, and cardiac tonics thus : digitalis, strophanthus, sparteine, cactus,
convallaria, adouidin, and suprarenal preparations. Caffeine and strych-
nine are both stimulants and tonics.

Adrenalin Chloride in Subcutaneous Injection* (20 minims of 1 : 1000
solution) is recommended by A. S. Myrtle7 in neurotic heart failure
attacks, for which he previously prescribed ^ grain strychnine and
Ti- to y^y grain strophanthin.

Dic/ita/ix. A new non-alcoholic preparation, uniformly active, sterile,
and non-irritating, for subcutaneous and internal use, has been experi-

1 Tlierapie der Gegenwart, No. 7.

2 New York Medical Journal, January 2, 1904.

3 Medical Standard, March, 1904.
* Lancet, January 20, 1004.

5 Ibid., November 28, 1903.

fi Medical News, September, 1903.

: British Medical Journal. April 30. 1904

THE HEART. 99

mentally tried by E. M. Houghton1 with satisfactory results. In cardiac
insomnia L. Feilchenfeld has had excellent results from an evening dose
of digitalis and morphine (0.015 mg. and 0.0025 dg., respectively).
Barie's article in the Presse Medicale, 1 903, sets forth the causes of failure
with the administration of digitalis and some of its contraindications.

T)avid Lees'2 Treatment for rheumatic endocarditis and pericarditis
includes, besides icebags and leechings, the steady administration of
large doses of sodium salicylate and bicarbonate (20 grains and 40
grains) regularly every two hours during the day, and every four hours
during the night for an adult (half this for a child aged six to ten years),
with increase in the doses until 150 to 200 grains salicylate are taken
daily. "Air hunger," the only evil result to be looked for, is obviated
by the alkali, which neutralizes the formic acid given out by the micro-
coccus rheumaticus, the toxin from the micrococcus being the agent
of dilatation. Strychnine may also be given at times. The patient is
to be kept warm, but not blistered. The same treatment is also suc-
cessful in chorea.

Antistreptococcic Serum in Acute and Chronic Rheumatism
has given Menzer3 excellent results. In 47 acute cases only 2 in-
stances occurred of any cardiac complication. Of 9 cases which had
become chronic 7 were cured and 2 much improved. Of 1 1 cases of
primary rheumatoid arthritis the 5 exudative cases got well, 2 others
improved, but 4 had advanced articular lesions and did not improve.

Heart Resuscitation by Massage in Chloroform Syncope.
A brief summary of the history of this subject is supplied by Bourcart,4
whose experiments recommend laparotomy and subdiaphragmatic mas-
sage in preference to direct massage through a thoracic and pericardial
incision.8 This method has already been successfully adopted in man
by Arbuthnot-Lane.6 The other method has recently been practised
successfully by Paul Fick.7

H. M. Cohen8 reports a successful case of combined diaphragmatic
or " bimanual massage of the heart."

D. G. Zersas,9 who is not in favor of cardiac massage, refers to a case
which he regards as the earliest on record (in the eighties), in which
several ribs were resected and the heart rhythmically compressed.

1 Medicine, Detroit, August, 1903.

2 British Medical Journal, November 21, 1903.

3 XXI. German Congress, Leipzig, Semaine Medicale, May 4, 1904.

4 Kevue Medicale de la Suisse Rom., October, 1903.

5 Tuffier and Hallion, Maag., Prus.

6 Lancet, November 22, 1902.

7 Centralblatt f. Chirurgie, September 5, 1903.

8 Journal of the American Medical Association, November 7, 1903.

9 Centralblatt f. Chir., 1903, xxx., No. 22

100 DISEASES OF THE THORAX AND ITS VISCERA.

Spina's Bulky [ntra-arterial Warm Saline [njections in
the direction of the heart arc described by A. Velich1 as successful in
animals if the cessation of the heart beat has not lasted longer than ten
minutes.

The simpler methods tried by Daniel X. Eisendrath2 include Koenig's
rhythmic precordial compressions, Laborde's tongue method, and Crile's
hypodermic injection of adrenalin.

1 Miinchener med. Wochenschrift, August IS, 1908.
Medical Standard, Chicago, March, 1904.

DERMATOLOGY AND SYPHILIS.

By WILLIAM S. GOTTHEIL, M.D.

DERMATOLOGY.

Acne. There is perennial interest in this well-worn subject, owing
to the facts that we are all called upon to treat it, and that we not in-
frequently fail to effect any permanent amelioration in its symptoms.
Gilchrist1 pleads again for the bacillus which he announced some three
years ago as the etiological factor. He claims that the bacillus acnes is
a definite and specific microbe, which he has found in all the smears
of 240 lesions taken from 86 different patients. Pure cultures were
gotten in many cases, and the organism was pathogenic to mice and
guinea-pigs. Gilchrist holds that the ansemia, constipation, and head-
ache that may be present are the results of toxic absorption, rather than
that they have any causal relation to the disease. Orlipski2 represents
the other extreme, and refers all cases to internal causes. Of course,
there are some acneiform eruptions that undoubtedly originate in the
blood, as those due to the ingestion of iodine, bromine, and chlorine,
though these are more properly grouped with the other dermatoses of
the same origin as iododermata and bromodermata. Others are as
undoubtedly external, as, for instance, the acnes due to the local use
of tar or paraffin or to the presence of the acarus folliculorum in the
sebaceous glands. In a very large proportion of cases, however, no
cause at all can be found. The patients are apparently in perfect health.
It is possible that the affection in these cases may be due to microbic
infection, and that Gilchrist's bacillus acnes, the micrococcus of Unna
and Hodara,3 or some other micro-organism, may ultimately be recog-
nized as the causative agent. We know nothing decisive about it as
yet ; but the fact that, as I always insist, antiseptic treatment of the
lesions and the skin in general is an indispensable part of any effective
treatment would seem to sustain the supposition.

Treatment was discussed at some length last year.4 Fox5 lays especial
stress upon general measures, baths, exercise, and restricted diet ; in

1 Journal of Cutaneous Diseases, March, 1903.

2 Allgemeine medicinisches Centralblatt ; Monatshefte f. praktische Derniatologie,
May 1, 1903.

3 Pkogressive Medicine, September, 1901, p. 135.

4 Ibid., 1903, p. 109. 5 Dermatologisches Centralblatt, August, 1903.

1 ( i o I) EBMA TO LOGY A \D S YP HI L IS.

fact, he claims that many of the cases would get well of themselves if
it were possible to put the patients upon a hygienic and dietary course
such as athletes undergo in training. He rejects lotions, salves, soaps,
etc., almost entirely, employing massage and curetting for the local
treatment. His ideas are excellent, but unfortunately quite inapplicable
in the immense majority of cases. Delicate females and young men
whose time is occupied cannot undertake it. It is well to go as far as
possible, however, in the direction indicated, and hygienic measures and
a restricted diet should form part of our treatment in every obstinate case.

Stack and Torok1 and Seheiir again recommend the Roentgen treat-
ment. I have said a good deal concerning this dermatotherapeutic
measure in previous reviews, and a year's added experience has in no
way changed my opinions. It is a remedy not devoid of danger, and
it is very uncertain in its effects. Cured cases have been reported,
and on undoubted authority ; yet 1 am sure that the curette, massage,
antiseptic lavage, and even ordinary ointments have a larger number
of successes to their credit. I should hesitate to employ it save in a
case that had absolutely resisted all other methods. A further criticism
of some of the cases that I have seen is that the operators used some of
the older and recognized general and local measures in the treatment
of their cases in addition to the radiotherapy.

Actinotherapy. This subject was thoroughly discussed last year,
and there remains only to uote the advances that have been made.
Good results in appropriate cases have been recorded by Gunni Busck,3
Dalpe,' Kaiser,5 Huber,6 Leredde and Pautrier,7 Montgomery,8 Fried-
lander,9 Rogers,10 and many others.

We are not here concerned with the favorable reports of the treat-
ment in internal tuberculosis and other affections. In lupus, tubercu-
losis cutis, rodent ulcer, epithelioma, acne, carbuncle, eczema, etc., cures
are reported by Morris and Dore,11 Francois,12 Dreyrr,1"' De Beurmann

1 Therapeutic Gazette, November 15, 1903.

2 Wiener klinische Rundschau; Journal of the American Medical Association, January
9, 1904.

3 British Journal of Dermatology, August, 1903.
1 Canada Medical Record, March, 1903.

5 Wiener klinische Rundschau ; Journal of the American Medical Association, July
11, 1903.

6 Wiener medicinische Wochenschrift ; Dermatologisches Centralblatt, March, 1903.

7 Actinotherapy, C. Naud, Paris, 1903.

8 Journal of Cutaneous Diseases, December, 1903.

9 Occidental Medical Times, March, 1904.

10 American Journal of Dermatology and Genito-urinary Diseases, 1903, No. 6.

11 Practitioner ; Therapeutic Gazette, August 15, 1903.

12 Bulletin de la Societe" Medicale d'Anvers; Dermatologisches Centralblatt, March,
1903.

13 Monatshefte f. praktische Dermatologie, February 1, 1904.

DERMATOLOGY. [03

and Degrais,1 Leredde,2 etc. Last fall I reported on four cases of lupus
erythematosus treated by this method.3 Three cases were cured ; it
must be admitted that they had not been of very long duration, having
lasted six mouths, one and two years, respectively. The fourth case
was a very bad one, had been present for eight years, and had caused
the transformation of a large part of the skin of the faee into cicatricial
tissue. The patient, coining from Central America, could only stay a
short time under treatment, and left but slightly improved. The
number of sessions required in the cured cases was but very few, being
22, 9, and 12, respectively. There was a slight amount of reaction
only ; uo matter how concentrated the light was applied, superficial
vesiculation could be induced, but there was usually only a moderate
swelling and redness, which subsided in a day or two. These are
certainly encouraging results in a disease of such recalcitrancy.

A few words about apparatus will be appropriate. There are
machines manufactured that are entirely useless from a- dermato-
therapeutic point of view. Finsen and his collaborators have taken
occasion in a number of communications to emphasize the fact that
power — i. e., amperage- -is necessary for effect. Superficial reaction is
no measure; in fact, I do not hesitate to say that deep effect is usually
in reverse proportion to it. Incandescent lamps, no matter in what
combination, are quite useless, and arcs running on currents of less than
10 amperes are not much better; 40 amperes is as little as should be
employed. I use 50 to GO, and Finsen's latest models run on 60 to 100.

One very important improvement has been made in the <(<-tiu<>litc
that I employed during the past year. The lenses have been put in one
setting, and the water-bath has been placed between them. The entire
light apparatus, lenses, and water-bath can be taken out and cleansed.
Besides this, the lenses are in direct contact with the water of the bath ;
in fact, they form its sides. Thus all danger of breakage is obviated,
an item of great importance with expensive lenses. I have had the
water in my bath almost at the boiling point without any damage. It
is also possible with this setting to go rapidly, within a minute or two,
up to the full strength of the lamp, instead of slowly running it up for
five or ten minutes, as before. I regard this as by far the most impor-
tant practical improvement of the year.

The new iron carbons of Bang and others that I mentioned two
years ago4 have not proven as effective as was hoped. Bogrow5 claims

1 Annates de Dermatologie et de Syphiligraphie, May, 1903.

2 Monatshefte f. praktiscbe Dermatologie, October 1, 1903.

3 International Journal of Surgery, October, 1903.

4 Progressive Medicine, September, 1902, p. 111.

5 Monatshefte f. praktische Dermatologie, August 15, 1903.

1 0 \ »ER MA TOL O Q Y A ND SYPH1 L IS

that they bum irregularly and are difficult to keep adjusted. Gunni
Busck1 found that the small dermo lamp took forty seconds to effect a
cutaneous reaction, the iron electrodes took ten seconds, and the ordi-
nary carbons eight seconds. 'The smaller apparatus was less than one-
sixtieth as effective as the large ones as a bactericidal agent. Whitfield2
says that these results agree closely with those obtained a year or so
ago by Professor Jackson and himself at King's College. Even Clasen3
and Kromayer,4 though advocating the smaller iron lamps, admit that
their action is superficial.

Finally, there remains to be mentioned the efforts that have been
made to favor light penetration through the skin in ways other than by
inconvenient and often inapplicable compressors. Dreyrr,5 working
in Fiusen's Institute, found that the addition of a little erythrosin to
nutrient media rendered the bacteria and infusoria in them sensitive to
the yellow and green rays, just as it did photographic plates. Thus
a layer of -skin 1.25 mm. thick protected a non-sensitized bacillus pro-
digiosus culture so that the organism lived under the light for eleven
hours. When the medium was sensitized they were killed in twenty-
nine minutes by the same light. In lupus he got a much quicker and
greater effect when he used a 1 : 1000 sterile erythrosin Griibler solution
in physiological (0.85 per cent.) salt solution. From 0.5 to 1 c.cm.
was injected, after Schleich's method, to sensitize an area of from 4 to 6
square cm. Four to eight hours later the actinotherapy was applied,
and vigorous reaction was gotten in fifteen minutes in well-vascularized
tissue, and in less time in cicatricial structures. I have had no personal
experience with the procedure. It would probably be impracticable to
give the injection several hours before treatment in any but hospital
cases ; but if the erythrosin could be applied in some absorptive medium
by the patient himself, it might be used. At all events, it is worth
trying by those working in this line, and especially in the bacterial
dermatoses.

Angioma. The senile type of this affection has attracted a good
deal of attention during the past year on account of its supposed re-
lationship to carcinoma. Lesser, and before him Trelat, claimed that
this existed, though Unna and Debreuilh have denied it. Raff6 leaves
the question open, nor can he decide whether the lesions in question

1 Monatshefte f. praktische Dermatologie, August 15, 1903.

2 British Journal of Dermatology, August, 1903.

3 Therapie de (iegenwart; Journal of the American Medical Association, October 17,
1903.

4 British Journal of Dermatology, August, 1903.

5 Monatshefte f. praktische Dermatologie, February 1, 1904.

6 Miinchener medieinische Woclienschrift ; Monatshefte f. praktische Dermatologie,
May 1, 1903.

DERMATOLOGY. 105

are true angiomata (new-growths) or merely dilatations (capillary
varices). They are rare before fifteen, frequent at twenty, and at sixty
to seventy years 88 per cent, of all patients have them.

Henking1 prefers electrolysis for their treatment in all cases where
the use of the knife is inadvisable, as where scars and shrinkage would
be bad, where they are extensive, especially in the cavernous forms,
and where hemorrhage might be dangerous, and, finally, where the
knife is objected to. He has treated 80 angiomata by this method,
employing the bipolar plan, and sinking the platinum needle into the
tumor. Carl Beck,2 of Chicago, advocates the subcutaneous ligation of
the vessels, from which he has gotten good results. The injection of
very hot water has been proposed by Wyeth and others. Hansell3
injects 50 to 70 per cent, alcohol.

Electrolysis is certainly the safest of these methods where excision
cannot be resorted to. I have seen great sloughing result from the
alcohol injections, and I am informed that it has occurred after the hot
water. The danger with electrolysis, as with the various hypodermic
methods that have been proposed, is that of thrombus formation and
embolism. I have seen three cases this winter in infants, two of which
were seated at the side of the root of the nose near the angle of the eye,
and one over the patent fontanelle and longitudinal suture, and all
three cavernous. None of the ordinary methods of treatment could be
advised, on account of the evident communication of the tumors with
the cerebral sinuses. Some cases have been reported cured by actino-
therapy, but these patients were entirely too young to keep quiet under
it. The only thing to do was to wait until the children got older.

In ordinary angiomata I employ electrolysis, using the unipolar
method. I shall not here go into its details. I can say in passing,
however, that there are two methods that I have tried on a number of
cases, and, though they have been recommended by authoritative names,
I have not had the smallest measure of success. They are the applica-
tion of bichloride of mercury collodion in varying strengths, and the
use of the caustic (25 or 30 per cent.) peroxide of hydrogen. I regard
both of them as absolutely useless.

Baldness. Bernheim4 in an article on the treatment of this con-
dition makes some very timely remarks. It should not, as is but too
frequently the case, be treated as a joke. It is usually due to an in-
fectious and contagious disease ; it is preventable by prophylaxis, and
can be cured in many cases if the sufferer and his physician have

1 St. Petersburg medicinische Wochenschrift, 1903, No. 15.

* Journal of the American Medical Association, January 9, 1904.

3 Bruns' Beitriige zur klinische Chirurgie, No. 1, Bd. xxxii.

4 American Medicine, July 4, 1903.

I Qtf /) EBMA TO LOG Y AND SYPHILIS.

patience enough. In the ordinary cases as seen in males its cause is
almost always a chronic seborrheal eczema of many years' standing, the
only symptoms of which are a moderate amount of itching, more or less
sealing or " dandruff," and a gradual thinning of the hair. It is prob-
ably due to a contagious organism, and the belief is gaining ground that
it is transferred by the barber's lingers and hair-brushes from one
patient to another. I know of no other common skin affection the
treatment of which is more satisfactory, provided it is begun early
enough and persisted in for a sufficient length of time.

Prophylaxis is dependent on the condition of the barber shops, which
will be considered later. I have said a good deal on its treatment,
under the head of Alopecia, in previous reviews.1 That advocated by
Bernheim is essentially the baldness cure proposed by Lassar some years
ago, and which I constantly employ. It consists, first, in the systematic
use of tar soap, which he prefers to make extemporaneously by adding
40 parts of birch tar to 60 parts of the tincture saponis viridis. The
scalp is to be thoroughly shampooed with this every day for eight
weeks, then every second or third day for eight weeks more. The
process should occupy ten minutes by the watch. After each shampoo
wash off with, first, warm and then cold water ; dry the scalp. Then,
with a woollen cloth, rub for five minutes with bichloride 1 part, water
.300 parts, glycerin aud cologne spirit of each 100 parts. Following
this rub the scalp dry with betanaphthol 1 to absolute alcohol 200
parts. Finally, inuuet a little of the following : salicylic acid 2, tinc-
ture of benzoin 3, neat's-foot oil, 100 parts. The soap removes the dust
and detritus, the sublimate is bactericidal and stimulant to the hair, and
the naphthol alcohol removes the fats and prepares the scalp for the
absorption of the oil.

It is necessary to be very explicit in the directions given to the
patient, and to have the time employed regulated by the clock. I
invariably write out the full directions. In suitable cases there will
be found a new-growth of lanugo hair in three months or less, and inside
of a year the bald places will be entirely covered. Unsuitable cases are
those of long standing in which atrophy of the glandular structures of
the scalp has taken place. When this latter is thinned, shiny, and
adherent, and when no gland orifices can be seen with a magnifying
glass, the hair bulbs are entirely atrophied, I know of no treatment
that will restore them.

Barber-shop Hygiene. As the barber shops are the chief source of
the contagion that causes the baldness so prevalent among men, some

1 Progressive Medicine, September, 1901, p. 136 ; September, 1902, p. 145; Sep-
tember, 1903, p. 119.

DERMATOLOGY. 107

attention has been paid to their regulation, and the Board of Health of
New York has laid down rules for their conduct. They are as follows :

1. Barbers must wash their hands thoroughly with soap and hot
water before attending any person.

2. No alum or other astringent shall be used in stick form. If used
at all to stop the flow of blood, it must be applied in powder form.

;i. The use of powder puffs is prohibited.

4. No towel shall be used for more than one person without being
washed.

o. The use of sponges is prohibited.

6. Mugs and shaving-brushes shall be thoroughly washed after use
on each persou.

7. Combs, razors, clippers, and scissors shall be thoroughly cleansed
by dipping in boiliug water or other germicide after separate use thereof.

8. No barber, unless he be a licensed physician, shall prescribe for
any skin disease.

9. Floors must be swept or mopped every day, and all furniture and
woodwork kept free from dust.

10. Hot and cold water must be provided.

11. A copy of these regulations is to be hung in a conspicuous place
in each shop.

I have not the least desire to quarrel with these rules, which are all
good, and are probably the best that can be promulgated under the
circumstances. They do not, however, go far enough. The chief
sources of contagion in the barber shops are the barber's hands and his
hair-brushes. The barber dips his fingers in water after each customer ;
I have never seen anywhere even a pretence at thorough washing.
And the hair-brushes are not cleansed, and I do not see how they can
be. They are comparatively expensive tools, and are ruined quickly by
too frequent washing. Measures that are radical enough to be efficient
cannot, I am afraid, be enforced. But the hair-brush might be done
away with entirely, I believe, or the metallic brushes and combs, that
can be dipped in boiling water, substituted for the ordinary kinds.
And proper hand washing can be insisted on. So far as my observation
goes, the utensil sterilization consists of a very infrequent dipping of
the tools into a dilute carbolic or formalin solution. It goes without
saying that this is entirely ineffective.

Burns. Burns, scalds, and frostbites belong to the dermatological
division in my Lebanon Hospital service ; this is the usual arrange-
ment on the Continent, and is the proper one. I have hence occasion
to treat a large number of these cases every year ; and I thoroughly
agree with Munson, who rejects all dry dressings and oils, and uses
only antiseptic wet dressings and cleanliness, exactly as he would with

108

DERMATOLOGY AND S YPHIL IS.

an ordinary wound.1 I have advocated this plan before,2 and additional
experience has only increased my favorable opinion of it. Grosse1 is
of the same opinion ; and though picric acid in 1 per cent, solution is
still advocated by Mil ward,1 MacLennarm,6 Bjorkman6 and others, com-
parative tests have in my experience conclusively proven the inferior
efficacy of the treatment.

Besides the general measures for combating shock when present, hot
bottles and drinks, ether or camphor hypodermically, etc., I open the
blebs at their most dependent portion, remove all necrotic fragments of
tissue and clothing that are not firmly adherent, and carefully apply a
1 : 20 liquor alumini acetatis or 1 per cent, boric-acid dressing. This
must be renewed as often as rendered necessary by the secretion, usually

Fig. 12.

Carbolic acid burns. (Author's case.)

once daily ; occasionally it can remain on for two days; but I do
not hesitate to have the patient dressed twice daily if secretion is very
abundant. When the first effects of the injury are over, a rise in tem-
perature, if there are no lung, kidney, or other complications, always
means the absorption of decomposing secretion from the wound, and
calls for more frequent renewal of the dressings, cleansing of the wound,
and removal of dead tissue. This treatment is the only one, and it is
kept up until epidermization is complete ; the nitrate of silver, skin or

1 Medical News, July 26, 1903.

2 Progressive Medicine, September, 1902, p. 152.

3 Archiv f. Dermatologie u. Syphilis, December, 1903.

4 Lancet, September 12, 1903. 5 Therapeutic Gazette, December 15, 1903.
6 Merck's Archives; Journal of the American Medical Association, April 25, 1903.

DERMATOLOGY. 109

epidermic grafting, etc., being employed to hasten the process. When
the denuded area is entirely covered a dusting powder can be used to
protect the delicate tissues ; but oils and ointments are never employed

at all.

Chemical injuries and frostbites are to be treated in exactly the same
way. Fig. 12 shows an extensive carbolic-acid burn occurring on the
hands of an orderly in my hospital service.

Chancroid. In the last review of this subject1 I stated that the
pathogenicity of the Unna-Ducrey cocco-bacittus was still doubted in
some quarters. This is hardly the case to-day ; the organism has been
successfully cultivated by a number of investigators, and the inoculation
experiments have given better results. Tomasczewski's2 work will serve
as an example of the rest. This observer was successful on blood agar,
and even with coagulated rabbit and human blood. The organism
grows in colonies of polymorphic rods, with a tendency to arrangement
in parallel rows, is uumotile, and is decolorable by Gram. The micro-
organisms were inoculable on man, even after a number of agar genera-
tions ; apes also were successfully inoculated, and cultures from their
sores produced true chancroid in man. This question may therefore
be regarded as settled.

A very rare localization of the affection is recorded by v. Leitner.3
A ten-year-old girl appeared with a chancroid of the left lower eyelid.
The author believes that it is the only case of the kind on record, since
it is not mentioned even in the latest text-books.

Brand weiner4 has treated a series of forty cases by the freezing method,
and recommends it very highly. In seven cases the results were negative
on account of the irregularity of the patients in coming for treatment.
In the other thirty-three the results were excellent. The nicer and its sur-
roundings are thoroughly cleansed with sublimate solution and dried
with absorbent cotton. The ethyl chloride spray is then applied at a
distance of 20 cm. for from three to five minutes, in accordance with the
size of the ulcer. The tissues are thoroughly frozen ; there is no danger
of gangrene. Reactive hyperemia and some hemorrhage follows thawing.
The criticism to be made of Brandweiner's cases is that after the
freezing he invariably used powdered iodoform as a dressing. This
alone is a common and frequently very efficient application ; and a
oertain number of the cases would undoubtedly have recovered under
it without any freezing at all.

1 Progressive Medicine, September, 1902, p. 156.

2 Zeitschrift f. Hygiene u. Infectionskrankheiten, 1903, Bd. xlii.; also, Deutsche
medicinische Wochenschrift, 1903, No. 26.

3 Orvosi-Hetilap, Monatshefte f. praktische Dermatologie, May 1, 1903.
♦ Wiener klinische Wochenschrift; The Prescription, September, 1903.

110 DERMATOLOGY AND SYPHILIS.

Kirstein1 advocates the use of the official tincture of iodine, and
claims wonderful results from it. It seems hardly possible that his
statement that it causes no pain is correct. He objects to the use of
pure carbolic acid, claiming that it penetrates too deeply and causes
very slowly healing ulceration.

On the whole, 1 find no reason to depart from the ordinary methods
in the treatment of these ulcerations. In public practice cleanliness
and iodoform fill the indications in most cases. Cauterization with the
galvanic point or with a mineral acid is required if the ulcers are ex-
tending rapidly. Refrigeration after Brandweiner's method, or heating
by holding a Paquelin point near the ulcer, can be reserved for the
rases that do not respond to the usual measures.

Chromidrosis. A peculiar case is recorded by Putman.2 What was
apparently an exudation of inky-black sweat appeared suddenly on parts
of the face of a young girl while she was riding in a street car. It
began on the eyelids, and then spread onto the cheeks. It was accom-
panied by no abnormal sensations. The skin was not affected, and the
exudation appeared at intervals for fourteen months thereafter. It is
worthy of note that the patient is said to have had six attacks of recur-
rent hysterical paralysis during that time.

Calcott Fox has reported two cases in which a deep bluish-black
pigment was exuded from the skin of the circumorbital region ; but in
almost all the other reported cases the exudation is red (the so-called
hrematidrosis), and has in some cases been proved to be due to a fungus
on the skin. They occur almost always in hysterical females, and it is
almost impossible to positively exclude deception.

Dermatitis, Bullous. These are always cases of interest on account
of the difficulties in classification and treatment. Urticaria, pompholyx,
syphilis, pemphigus, various drugs, and even eczema may occasion it.
In a previous review3 I recorded a case for which pompholyx is prob-
ably the most appropriate designation. A similar one has been de-
scribed by C. J. White,4 in which a female, aged twenty-three years,
had a left-sided, recurrent bullous eruption, the individual lesions of
which lasted one week, and then disappeared without leaving any mark.
In the discussion on it at the American Dermatological Association
Bronson admitted the impossibility of making an absolute diagnosis in
many of these cases ; Gilchrist believed the lesions to be of hysterical
origin, and Shepherd and Engman thought them artificial, and not liable
to appear if the patient was carefully watched.

1 Dermatologisches Centralblatt, April, 1903.

2 New York State Journal of Medicine, July 4, 1903.

* Progressive Medicine, September, 1902, p. 161.

* American Medicine, May 23, 1903.

DERMATOLOGY. Ill

Krysztalowicz1 has reported a case of the kind in which lie demon-
strated the dependence of the affection upon an external streptococcus
infection. Klotz2 records one in which the patient, suffering from
detachment of the retina, was given iodide of potassium, and got an
eruption therefrom. He was then given iodipin, 10 per cent, solution
in teaspoonful doses three times a day, with the result of a general
bullous eruption.

The diagnosis in most of these cases must be made by the concomi-
tant symptoms and the history, since there is often nothing characteristic
about the eruption itself. In a number of cases there are no urticarial
or eczematous symptoms ; there is no history of drug ingestion or of
syphilis ; pemphigus is to be excluded by the benign course of the
disease and the absence of constitutional involvement, and for them the
designation of pompholyx or bullous dermatitis is appropriate. In
point of fact, the entire subject of the boullous skin eruptions is in
urgent need of study and revision.

Dermatitis Venenata. This is a common affection in country
districts in the summer season, several plants possessing the faculty
of exciting an acute vesicular dermatitis in the skins of susceptible
individuals. Klotz3 advocates the use of ichthyol, applying it in 33 to
50 per cent, watery solution. All old salve-remains are to be removed
with benzin (which is the best general cleanser for skin cases in office
practice) ; large vesicles are to be opened with the curved scissors, while
small ones may be left intact, and pads of absorbent cotton soaked in
the ichthyol applied. Dressings must be renewed once or several times
a day, in accordance with the amount of secretion. Clevenger4 recom-
mends ammonia-water as the best application ; I should hesitate to
employ it save in very dilute solution. Sodium sulphate 1, glycerin 4,
camphor-water 32 parts, is a favorite dressing ; and if an ointment is
desired, there is nothing better than the ichthyol-iodide of lead combi-
nation, viz., ichthyol and lead iodide 1 drachm, petrolatum 1 ounce.

I have for many years employed an application not mentioned in
the books, but which has given me great satisfaction, and is at least as
efficacious as any of the others. I use the old U. S. solution of morphine
— 1 grain to the ounce of distilled water — keeping wet dressings soaked
in it constantly applied to the inflamed skin. There is no absorption,
of course, though there seems to be a considerable local sedative effect.

Eczema. Another year has passed without any special confirmation
of the researches of Bender, Bockhardt, and Gerlach as to the cause of

1 Dermatologisehes Centralblatt, May, 1903.

5 Journal of Cutaneous Diseases, July, 1903. 3 Ibid.

* Medical Brief, September, 1903.

112 DERMATOLOGY AND SYPHILIS.

eczema, to which I called attention in L902.1 The theory of its
dependence upon the toxins of the pas organisms was an attractive one ;
hut the little that has been done has not proved confirmatory of the
investigations of these authorities. The growing impression that eczema
is not a disease at all, but is merely a term used to designate a number
of very varied reactions of the skin to differing external and internal
stimuli, is gaining ground. Brocq2 voices this when he says that there
are eczematous individuals in whom many different things, sunshine,
wind, light, dust, dyes, intoxications, autointoxications, diseases of
orpins, worry, nervous impressions, etc., will occasion it. Hence the
importance in individual cases of attempting to ascertain the factor that
causes the reaction. Hence, also, the importance of such measures as
change of air and environment, lavage of the gastrointestinal tract,
milk diet, etc. The local treatment, from his point of view, is entirely
secondary. I cannot entirely agree with this, though there is certainly
much truth in what he says. It is evident enough in the obstinate
infantile forms of the disease, where we can effect nothing permanently
beneficial until we regulate the gastrointestinal tract and the feeding.
With adults, too, 1 am insisting more and more on the importance of
general hygienic measures. Proper exercise, a rigid modified or partial
milk diet, change of air and scene ; these often do more for our patients
suffering from chronic eczema and psoriasis than all our prescriptions.
Rev3 makes a very cogent plea for more attention to this neglected
aspect of the eczematous disease.

There is not much that is new to record concerning treatment.
Wallis4 reiterates his recommendation of the employment of clay paste,
which is really a permanent moist dressing. The fact that water is
irritant and injurious in some forms of eczema has become common
medical property in the shape of an impression that it must be scrupu-
lously avoided in every case of eczematous disease. This is proved to
be a mistake by the fact that watery dressings, such as those of liquor
alumini acetatis, or boric acid, are usually the very best local measures
that we can employ in some of the very acutest eczemas. Wallis
claims that water has a destructive action upon the cytoid corpuscles
abundant in pus, and that this action is increased by the presence of
alkalies, especially of carbonates, even in minute quantities. For the
last six years he has used wet sterilized clay as a dressing in these cases ;
it holds the water and assists osmosis, has a therapeutic value from the
mineral salts that are present, and the absorbent earths have antiseptic,

1 Progressive Medicine, September, 1902, p. 164.

2 Journal of the American Medical Association, May 16, 1902.

3 .Tahrbuch f. Kinderheilkunde ; Medical Review of Reviews, July 25, 1903.

4 Therapeutic Gazette, September, 1903.

DERMATOLOGY. 113

alterative, astringent, and sedative actions. Clays with much kaolin
are to be preferred, and the dressing is kept moist by applying a wet
towel over it several times daily. He adds a little petrolatum, incor-
porated by means of ichthyol as an emulsifying base. His standard
combination is kaolin 50, water and petrolatum of each 25 parts, with
4 per cent, of ichthyol. This remains moist for twenty-four hours or
more. Acute cases require less petrolatum and more kaolin. Talcum,
starch, and zinc oxide may be added as desired ; glycerin must be
added with caution, as too much of it is irritant.

A number of writers have used radiotherapy in the treatment of
eczema ; and possibly, as Lassar1 states, chronic indurated cases,
especially of the hands, may be benefited by it. The objections to its
employment, however, are such that if used at all it should be reserved
for the very few cases that prove recalcitrant to the usual methods.
Block2 uses the high-frequency current in all cases, acute or chronic,
employing the Oudin resonator with a coil or static machine. He ad-
vocates the fine metallic brush electrode for the chronic and the glass
electrode for the more acute cases. He claims most excellent results.
Itching was relieved in 95 per cent, of the cases, and a series of eleven
varied ones was cured.

I can express no opinion on these results. Two points, however, are
worthy of mention : In the first place, serial cases are of value only
when coming from sources that render it certain that all elements of
error have been avoided ; and in the second place, submitting all
forms of disease to one and the same therapeutic procedure seems
hardly appropriate. If radiotherapy will cure all the varied disease
forms that we call eczema, we may well put the rest of our the-
rapeutic armamentarium upon the shelf so far as this affection is

concerned.

»

Erysipelas. Newcomb3 records some very unsatisfactory experi-
ences in this disease. He had ten cases, seven of which were children
twenty-seven days to one year old. Nine cases were fatal, a mortality
of 90 per cent. Records of failure are assuredly of great value, prob-
ably more than those of the successes that are so freely published. Yet
it does seem likely that some faction other than the erysipelas coccus
alone was concerned here. I see a good deal of erysipelas, both of
the facial and the more generalized variety, in the course of the year ;
and I have never found the mortality to be more than a very small
fraction of that recorded above. As regards the treatment, the author

1 Therapie der Gegenwart ; Journal of the American Medical Association, January 23,
1904.

2 American Electrotherapeutic and X-ray Era, October, 1903,

3 Monatshefte f. praktische Dermatologie, May 1, 1903.

1 1 4 DERMA TO LOO Y AND S YPHILIS.

found the antistreptococous serum quite useless, and regards ichthyol
as still the Host remedy at our disposal.

Attention is called by Farlow1 to the importance of erosions of the
septum nasi as points of entrance of the infection. Experience has
shown with fair conclusiveness that an inflammatory focus of some kind
is always the starting point of the disease. An acne pustule, a crusted
rhinitis, a suppurative otitis, or something of the kind, will always be
found. These conditions must be attended to when treating the case,
and the main clement of the prophylaxis of future attacks is the cure
of the condition that permits of them. I observed a case a year or two
ago in which the patient, an elderly gentleman, had had several attacks
vearlv for a long time. They always began around the lobe of one or
the other ear ; and examination revealed the fact that he had long had
a chronic eczema of both external auditory canals. This led to con-
stant picking and scratching, and consequent infection. He has not
had any attack since his eczema has been cured.

A few writers, such as Jarcho,2 still advocate the antistreptococcus
scrum ; most of them, like Denyo,3 find it absolutely without effect in
the disease. Tregubow4 employs a modification of the Rabinovich
cauterant treatment. He uses alcohol ignited on cotton, and held about
1 cm. from the affected skin so as to produce a burn of the first degree.
This he does two or three times daily, and claims that it usually has a
good effect in two days. I am very sure that the method will never
be popular here.

Krause5 has tried the red light treatment in a number of cases, and
thinks that he gets better results without than with it. Pollatschek6
had 300 cases, with 14 deaths ; 33 were treated with the red light, 12
with collargolum, and others with mesotan, etc. His best results were
gotten in the 80 cases treated with ice-cold compresses of liquor Burowii
(liquor aluminii acetatis), although in bad cases he advises the use of
colloidal silver intravenously.

It is a question in my mind whether ichthyol is sufficiently beneficial
in these cases to compensate for the serious diagreeabilities that it
entails. An erysipelas patient looks frightful to his friends, and so
does his bedding. In many of the cases that I have seen recently I
have advised only the use of cold compresses of boric acid or Burow's

1 Boston Medical and Surgical Journal, December 17, 1903.

2 Wratch, Dermatologisches Centralblatt, July, 1903.

3 Presse Medicale Beige, 1903, No. 17.

4 Deutsche medicinische Wochenschrift; Monatshefte f. praktische Dermatologie,
May 1, 1903.

5 Therapie der Gegenwart ; Journal of the American Medical Association, January 9,

1904.

6 Ibid.. December 12, 1903.

DERMA TO LOGY. 115

solution. I believe that they have done just as well as the ichthyol
cases, and I am very sure that the patient and the people around him
have been very much more comfortable.

Epithelioma. These cases are still being treated with the x-ray all
over the country. Among many others, Pfahler1 reports three cures
in four cases, and Pugh2 four cases with good results. I do not for a
moment presume to doubt either the correctness of the diagnosis or the
permanency of the results recorded by these and other observers. But
I have yet to see the first radically cured case ; and I am not the only
dermatologist who, perforce, occupies a somewhat skeptical position
on the subject. On the other hand, I have seen a number of absolute
failures. Thus I saw a case with a small rodent ulcer of the ala nasi
a year ago, in which radical treatment was refused. During the winter
he had thirty-five x-ray sessions at the hands of some very experienced
Boston practitioners. The result was an increase of the lesion to double
its former size and depth, with what was practically a confession of
failure on the part of the operators.

On the other hand, we have procedures of proved value, which have
stood the test of time, and by means of which hundreds and perhaps
thousands of cases have been cured permanently. I refer to the caustic
treatment, which I decidedly prefer to the knife in all cases in which
it is applicable. I employ nothing else unless I* am compelled to. The
case above referred to was cured in a very short time by its means ;
and past experience assures me that the cure is entirely permanent. I
cannot here go into the details of the method, but I unhesitatingly
recommend it in every case of epithelioma, rodent ulcer, Paget's disease
and the like.

It has also been brought to my notice that epithelioma cases unsuc-
cessfully treated with radiotherapy suffer some peculiar damage of the
skin in consequence of the treatment, even when there is nothing visible
to show it. They react excessively to instrumental and cauterant treat-
ment ; wound healing and casting off of dead tissue is abnormally pro-
longed. Their course after interference is entirely different from what
occurs in tissues that have not been previously treated with the x-ray.
Undoubtedly the ray causes some profound change in cell nutrition.

Feigned Eruptions. Cases of feigned dermatoses are not so very
uncommon, and they are very troublesome when encountered. We
may feel quite sure that the dermatosis is an artificial one, yet the con-
comitant circumstances may seem entirely opposed to any such supposi-
tion, and the most careful search may fail to reveal the exact etiology

1 Therapeutic Gazette ; Monatshefte f. praktische Dermatologie, May 1, 1903.
' British Medical Journal ; Monatshefte f. praktische Dermatologie, May 1, 1903.

116

DERMATOLOGY AND SYPHILIS.

of the lesions. I have met with not less than three eases during the
Lasi few years.

The first was that of a young man who had a number of deep circular
ulcerations in the skin of the anterior surface of both thighs. They
were evidently artificial, though the patient professed entire ignorance of
their etiology. It turned out later that one day he had been seated,
drunk and asleep, in a chair near a stove in a saloon. Some companions,
endowed with a delicate sense of humor, had heated a number of pennies
in the stove and placed them on his lap and knees. The spree had been
a prolonged one, and the patient had been quite honest when he disclaimed
all knowledge of the occurrence. The information as to the cause of
the lesions was obtained incidentally from a friend.

Fig. 13.

Feigned eruption ; lesions due to cauterization. (Author's case.)

The second case was one in which even the physicians were deceived.
The patient was a girl aged ten years, with a history of several attacks
of paralysis in the past — evidently hysterical, since they were recovered
from suddenly— and of a very violent and excitable temperament. The
history as given by the mother was detailed and explicit, For over a
year past the child had had sudden and profuse hemorrhages from the
unbroken skin of the face and hands. Her pillow would often be soaked
through with blood in the morning. The attacks came on suddenly
and without warning, and a number of them had occurred while the
child was with her mother and under close observation. The patient

DERMATOLOGY.

117

was carefully observed for a number of weeks, and while we never saw
an actual hemorrhage while it was occurring, we saw a number of them
immediately thereafter, with the blood still fluid on the face, hands, and
clothes. The skin underneath was sometimes scratched and excoriated,
but more often it was entirely normal. One attack took place while
the child was at the office of my chief of clinic, and the observer felt

Fig. 14.

Feigned eruption, bullous type : early stage. (Author's case. |

very positive at the time that the blood exuded spontaneously from the
unbroken integument. Nevertheless, we finally came to the conclusion
that the injuries were self-inflicted, probably by violent friction of the
parts against some rough surface. How the child sustained the injuries
that appeared at night we never definitely ascertained, nor did we find
the source of the blood in the instances where there was no lesion. But

118

DERMATOLOGY A SI) SYPHILIS.

moral suasion, together with threats as to the measures to be employed

if the lesions reappeared, checked them entirely.

The third case was one that 1 published during the course of the last
winter.1 The patient was a single female aged twenty-eight years, who
had had a child ten years before. She had been hoarse since childhood,
and had had seine abdominal trouble, for which she had been operated
on some live years ago. She had gastroenteric attacks (nausea, vomit-

Fig. L5.

Feigned eruption ; later sta^e. (Author's case. )

ing, and diarrhoea) from time to time, each one of which was accom-
panied by an eruption composed of large bullre. There was apparently
an abdominal tumor, but none was found on careful examination, it
being simulated when in the upright position by the contraction of the
abdominal muscles. There was nothing in the larynx ; the aphonia
was hysterical.

1 Journal of Cutaneous and Genito-urinary Diseases, January, 1904.

DERMATOLOGY.

119

During the months that she was under observation she had repeated
outbreaks of the bullous exanthem, some of which wrere very extensive,
and made her very miserable. Their circular or oval shape, presence
only on the abdomen, thighs, legs, arms, and the accessible parts of the
back, and the entire freedom of the face, hands, and interscapular
space, at once aroused suspicion of their adventitious origin. Yet I had

Fig. 16.

Feigned eruption ; last stage. (Author's case.)

her twice for protracted periods in Lebanon Hospital, during which
time she had several attacks, without attendants or staff being able to
ascertain how the lesions were produced. After leaving the hospital
she thought that I lost interest in her case, and the lesions assumed
remarkable shapes. The bulla? became long strips, sometimes six or
eight inches in size, and many of them appeared as large round or oval

120 DERMATOLOGY AM) SYPHILIS.

drops, with a prolongation from their lower margins, Looking as if some
fluid had beeD dropped on the skin and the excess had run down. The
agent employed to produce the lesions was probably carbolic acid ; the
bullae did not resemble those of cantharides.

Qiese oases illustrate the difficulty occasionally experienced in arriv-
ing at a correct diagnosis. Van Harlingen1 has collected the material
in reference to the so-called hysterical dermatoses, and classifies it.
He is inclined to think that proof of self-infliction is possible in but
very few cases. White2 also proclaims his belief in their genuineness.

Furunculosis. A good deal has been written during the past year
on the treatment of this affection. Bidder3 reiterates the therapeutic
advice that he gave as long ago as 1887. It is to treat each separate
lesion by an injection of a 2 to 3 per cent, carbolic-acid solution in
water, the needle being inserted through the healthy skin at the edge
of the tumor and pushed to its centre. A small amount (a few drops)
ouly need be injected. If the furuncle is at all large more than one
puncture and injection must be made on different sides, and if the lesion
is carbuncular at least four injections should be made.

It seems strange that this treatment, which has now been before the
profession for many years, has not been more popular. It is true that
there is some rather acute pain for some time after the injection, but
it is not especially severe, and the slight operation itself can be done
painlessly with the aid of the ethyl chloride spray. It is certainly the
quickest method of dealing with the lesions, and will sometimes abort
them when employed in the early stages. Even Jarisch,4 while he does
not like the injections, admits that they shorten the necrotic process.

Moritz Cohn5 has been a sufferer from furunculosis himself, and lays
down the following rules for its treatment :

1. Internal medication, with the possible exception of the purgative
waters, is useless.

2. Each beginning furuncle is to be inuncted with a pea-sized portion
of the following ointment daily: ichthargan 10, aq. dest. 3, glycerin
10, vaselin 'flav. 400.

3. If eczema is present use a 1 per cent, ichthyol paste.

4. If the genital region is affected use the galvanocautery for begin-
ning foci, evacuate pus, and apply the ichthyol paste.

5. Incisions are required only when there are large inflammatory
accumulations.

6. Order daily washings with ichthyol or sulphur soap.

1 Cincinnati Lancet-Clinic, September 26, 1903.
1 Journal of Cutaneous Diseases, September, 1903.

3 Deutsche med. Wochenscbrift ; Monatsliefte f. praktische Dermatologie, May 1, 1903.

4 Die Hautkrankheiten, Vienna, 1900, p. 459. 5 Dermatolog. Central., May, 1903.

DERMATOLOGY. 121

Desfosses1 advises the application of tincture of iodine after the
manner recommended by Boinet in 1865, or 90 per cent, alcohol com-
presses to abort the furuncles. When the lesions are more advanced he
employs a 2 per cent, carbolic water spray for two hours daily, covering
all the affected area. For the tension and pain he advises 1 : 2000
sublimate wet dressings. The tumors are to be opened when " ripe."
Internally he administers yeast, which he considers a specific, and better
than any other remedy. Trenit62 uses 1 : 500 pyoktanin solution, one-
half to one syringeful, entering through the healthy tissue, and making
the entire region blue. Guensburg3 pleads for a vegetarian diet in
furunculosis, which does good on account of the lessened ingestion of
albuminoids. Finally, Wright4 recommends a vaccine made from
staphylococcus albus and aureus cultures, about which 1 have no further
information.

I regard external and internal disinfection as a most important element
in the treatment ; in addition to the restricted diet (less albuminoids)
and saline purgatives, I use betanaphthol-bismuth, or some similar pre-
paration in full doses. Thorough cleansing and disinfection of the entire
affected area one or more times daily is necessary, for local infection of
neighboring follicles is a main factor in many of the obstinate cases.
An occlusive antiseptic dressing is necessary in some cases. Beginning
infected foci are at once pierced with a toothpick dipped in pure car-
bolic acid ; larger ones are treated with the carbolic injections as de-
scribed above. Large lesions are freely incised, and the very largest
ones enucleated, an ordinary antiseptic wet dressing being then
applied.

A very important point in the treatment of the more chronic forms,
where the patient has a succession of furuncles, is change of air and
environment. Some cases are exceptionally obstinate until they are
sent away.

Hirsuties. Reference has been made in the past5 to the prevalence
of this condition in the insane. In 1000 insane women in Paris 497
had a distinct mustache ; while only 290 per 1000 in the general
hospitals had it.

These latter, however, often had a family or personal history of
neuropathy or mental degeneration. The exact proportions of the
patients thus affected were : senile dementia, 64 per cent. ; general
paralysis, 56.6 per cent. ; dementia precox, 42 per cent. ; idiots and

1 Presse Medicate, 1902, No. 55.

2 Monatshefte f. praktische Dermatologie, May 1, 1903.

3 Dermatologisches Centralblatt, May, 1903.

4 Lancet; Monatshefte f. praktische Dermatologie, May 1, 1903.

5 Progressive Medicine, September, 1901, p. 171 ; 1902, p. 173.

122

DERMATOLOGY AND SYPHILIS.

imbeciles, 38.8 per cent.; epileptics, 37 per cent.; and other mental
affeotions, 17. 8 per cent.

I have already described the only efficient and safe method for the
relief of the affection. Yon Stalewski' says that sharp needles usually
go u Tong, make false passages, do not destroy the roots, and leave scars
He therefore uses one with a minute pear-shaped tip, which can only
enter the hair canal, and which he has found very effective. They are
not, so far as 1 am aware, obtainable here ; and I see no reason to give
»'1> the ordinary watchmaker's broach, which have I used for many
years with perfect satisfaction. Von can tell by the feel when you
have not entered the canal, and with practice you can manoeuvre
properly almost every time.

For some time past j ,,ave uged hydrogen ^^ ag recommende(]
by brallois, to bleach the hair in locations, as on the lip, where electric

Fig 17.

Keloid. (Author's case.)

epilation is painful and not very satisfactory. It should be applied
with a pledget of cotton for a few minutes several times daily. I have
not found, as Gallois did, that the hairs finally bleach, shrink to lanuo-o
break off, and disappear. But it does decolorize the hair, and is useful
in those troublesome cases with an abundant lanugo growth for which
patients insist on something being done.

Keloid. Leredde3 makes a plea for the surgical treatment of this
intractable affection. Extirpation should be done with full antiseptic
precautions, and the line of incision should be far outside the lesion.
In fact, the case should be handled as if it were a very virulent, auto-
inoculable tumor. He claims to have had some success ; and Brocq
and Barthelemy agreed with him that it was effective in certain cases.

1 Dermatologisches Centralblatt, May, 1903.

2 Cincinnati Lancet-Clinic, April 4, 1903.

3 Archiv f. Dermatologie u. Syphilis, January, 1904.

DERMATOLOGY. 123

Perrin1 has gotten good results in one case in which the lobe of the ear
was affected by means of bipolar electrolysis.

In spite of these more hopeful views, however, the attitude of derma-
tologists in general toward these distressing cases has not changed.
Tschlenow2 gives an absolutely hopeless prognosis as regards cure in
connection with a case that had 431 of these tumors, varying in size from
a lentil to a walnut. Gaucher and Milian3 showed a bad case at the
French Dermatological Society that had been repeatedly operated on.
The excisions were very large. I myself have gotten no results either
from extirpation, scarification, electrolysis, or actinotherapy. Probably
the best service that we can do these patients is to persuade them to let
their keloids alone.

Leprosy. Lament4 states that there are over 30,000 lepers in Burmah ;
there are no asylums, neither the English nor the Burmese Government
care for them, only the French mission priests keep barracks for their
reception. In Madagascar 700 cases are interned in the Norwegian
lepro-series ; 209 new cases were taken in in 1901.5 Tonkin1' studied
220 cases in Central Soudan. Gliick7 found 200 cases in Bosnia and
Herzegovina. Ehlers,8 in his official investigations made at the instance
of the Danish Government, found 102 lepers in the Danish West Indian
Islands. On the other hand, the number of cases in Norway and the
Sandwich Islands is decreasing. In the latter Governor Dole's'* report
showed a steady decrease in the number of new admissions ; there were
454 in 1890 to 1892, and 254 in 1899 to IDOL Filaretopoulo10 esti-
mates the entire number of lepers throughout the world at 300,000.

McDonald11 and Judson Daland12 have considered the question of
diagnosis at length. The microscope is the final test, and no case
should be declared leprous until it has been used. Macules or leuko-
dermic spots are present in 89 per cent, of the cases. Lepromatous
nodules are present in 74 per cent, of the cases. Thinning or loss of
the brows or lashes is seen in 63 per cent. Atropic lesions, contrac-
tures of the fingers, and enlargement of the ulnar nerve are present in
32 per cent. The plantar ulcer is found in 26 per cent. Absorption
of the phalanges and elephantiasis of the hands and feet are seen in 16

1 Annales de Dermatologie et de Syphiligraphie, May, 190:!.

2 Derniatologische Zeitschrift, 1903, p. 120.

:i Annales de Dermatologie et de Syphiligraphie, December, 1903.

4 Dermatologisches Centralblatt, July, 1903.

s Ibid. ° Lancet, April 18, 1903.

7 Monatshefte f. praktische Dermatologie, November 1, 1903.

8 Dermatologisches Centralblatt, July, 1903.

9 American Medicine, March 21, 1903.

10 Dermatologisches Centralblatt, May, 1903.

11 Journal of the American Medical Association, June 6, 1903.

12 Ibid., November 7, 1903.

124 DERMATOLOGY AND SYPHILIS.

per cent. Facial paralysis is found in 9 per cent. Anesthetic areas
must be carefully searched for, and several of the above symptoms
must be found before the diagnosis becomes probable.

1 1 is reported that ten patients have been released as cured from
Molokai.1 In the absence of further information on the subject it'
would probably be safer to believe for the present that they were cases
in which the diagnosis of leprosy has turned out to be a mistake. For
though the Hawaiian Government has appropriated $2000 for Dr. Goto's
leprosy treatment, the testimony shows that, like some other remedies,
it alleviates the symptoms, but is not a cure for the disease. De Luca2
has treated two eases with intravenous mercury injections after Bacelli's
method, and in both the ulcerations healed promptly. He does not
believe this to be a mere coincidence.

Chavlmoogra oil deserves as much confidence as anything in the
treatment of the disease, and Danlos3 uses it per rectum where there
is gastric intolerance. The rectal discharges the day after the injection
show no oil ; it is therefore absorbed. He employs an emulsion of 12
c.c. of the oil with 75 c.c. of milk for each injection.

Lupus Erythematosus. As stated in the section on actinotherapy,
I regard that method as one of the best at our command in this obsti-
nate affection. Norman Walker4 holds the same opinion. His atten-
tion was drawn to it by the observation that a patient affected with the
disease had his face much improved by exposure to the glare of water
while fishing in the Highlands. Since then he has treated a number of
cases in this way ; some were brilliantly successful, and all were im-
proved. He uses adrenalin chloride, 1 : 4000, to exsanguinate the
tissues before applying the light. Hollander5 claims to have gotten
very good results from the use of quinine in large doses internally and
tincture of iodine externally. Pisko recently showed some remarkable
results in very extensive cases at the Manhattan Dermatological Society,
obtained by the use of pure trichloracetic acid. The application is to
be lightly made, and once only, for it is very painful. Sloughing
occurs if it is too freely done. I have had no experience with it, but
1 believe that the remedy is worth trying.

Lupus Vulgaris. It is a pity that the Finsen treatment, so effica-
cious in this affection, is still beyond the reach of the great majority of
patients affected. Every country in Europe now has public institu-

1 Pacific Coast Medical Journal, August, 1903.

1 Gazzetta degli Ospedali, vol. xxiv. p. 17.

s Bulletin Gen. de Thdrap. ; Journal of the American Medical Association, March 28,
1903.

* Scottish Medical and Surgical Journal, June, 1903.

5 Berliner klinische Wochenschrift ; Monatshefte f. praktische Dermatologie, May 1,
1903.

DERMATOLOGY. 125

tions for the purpose ; there is not, to my knowledge, a single one in
this country. Sorensen1 admits the pre-eminent value of the treatment,
but in its absence uses ethyl chloride after Dethlef sen's method.2
Dreuw3 uses a modification of it. He first freezes the area fully with
ethyl chloride, and then applies crude hydrochloric acid until the parts
turn grayish white. An indifferent powder is then applied ; the scabs
fall off in three or four weeks. He says that the method is cheap and
efficacious, which I do not doubt. But I should hesitate loug before
applying such destructive measures to the face. I should prefer the
potassium permanganate method,4 which has recently been advocated
again by Hall-Edwards.5 For its details the reader is referred to the
review in Progressive Medicine for 1902.

The Becquerel rays have been tried in this affection by Halkin.6
They have a superficial necrotizing effect, but none at all, macroscopic
or microscopic, on the deep-seated nodules.

Lichen Planus. In extensive cases of lichen planus the mucosa
are generally affected ; but Delille and Druelle7 report a unique case in
which the buccal and preputial mucosas were the only parts involved.
Not only were the lesions typical, but a portion of the preputial layer
was excised, and the diagnosis confirmed microscopically. Dubreuilh and
Le Strat8 had three cases in which the palms and soles were involved.
They confess that the diagnosis would have been impossible if there
had not been typical patches of the disease on other parts of the body.
The palmar and plantar lesions consisted of lentil-sized, reddened,
slightly raised spots, with slight hyperkeratosis ; these become confluent
into large irregular plaques. Dubreuilh9 also describes the affection
as seen in the nails.

In connection with the description of a case affected with lichen
planus and scabies at the same time, Hallopeau and Jomier19 call atten-
tion to the occurrence of lichen planus lesions wherever the skin is
irritated, as by scratching. This occurrence has long been known to
me, and in my clinic it is customary for diagnosis and demonstration
purposes to make some pin scratches on the patient's body, and watch
the development of the lichenoid papules along the tracks thus made.

1 Hospitalstidende, Nos. 19 and 20, Bd. xlvi. ; Journal of the American Medical
Association, August 29, 1903.

2 Progressive Medicine, September, 1901, p. 182.

3 Dermatologisches Centralblatt, October, 1903.

* Progressive Medicine, September, 1901, p. 180.
6 British Medical Journal, June 27, 1903.

6 Archiv f. Dermatologie u. Syphilis, May, 1903.

7 Annales de Dermatologie et de Syphiligraphie, 1902, p. 209.

8 Archiv f. Dermatologie u. Syphilis, July, 1903.

9 Annales de Dermatologie et de Syphiligraphie, 1901, p. 606.
10 British Journal of Dermatology, October, 1903.

126

DERMA TOL OG Y A ND SYPHILIS.

I have never known the reaction to fail in an undoubted case, and I
regard it as characteristic.

A very extensive case of lichen planus was on my hospital service
this winter. Hands, palms, forearms, arms, face, the entire lower
Limbs and feet, as well as large areas of the trunk, were involved, as
were also all the visible mucosa*. The papules became so closely aggre-
gated that they formed large raised, erythematous, and scaly masses.
All the limbs, as well as the face, were so swollen for weeks that the
patient was absolutely bedridden. Such cases are rare, and very dis-
tressing. The pruritus was very great, and the patient suffered much
from want of sleep on account of it. The treatment was the standard
one, which is the only plan which I have found of service. Arsenic
was administered up to the point of tolerance in the shape of daily
hypodermic injections of a 1 per cent, solution of sodium arsenate, and

Fig. 18.

Lichen planus. (Author's case.)

1 : 2000 bichloride wet compresses applied locally. Lichen planus is
one of the few dermatoses in which arsenic is efficacious, and it should
be given fearlessly, its only limitations being the effect on the disease
and the saturation of the patient's system with the drug.

Neuroses (Cutaneous). Of these the most important are those char-
acterized by itching. This is the symptom of all others in cutaneous
affections that we are most frequently called upon to relieve, and while
in many cases it is of little importance, in others it forms the chief or
the only symptom, and obstinately resists all our efforts at ameliora-
tion. It is in rare instances so severe as even to menace life. In a
case of general erythrodermia that came under my observation some years
ago all the ordinary and many of the extraordinary measures entirely
failed to give the patient relief. For weeks external and internal
remedies were tried. The patient was in a perpetual state of torment.

DERMATOLOGY. 127

He was absolutely unable to work ; at night he could not rest in bed,
and spent his time roaming about the streets. For eight, ten, or twelve
days he could get no sleep at all. He would come to the clinic hag-
gard, staggering, with bloodshot eyes and half-demented. Then, utterly
exhausted, he would have a few hours of trance-like sleep, and then
have another period of insomnia. Even large doses of morphine hypo-
derm ically and chloroform narcosis, to which I was finally compelled
to resort, gave him no relief. The outlook for a time was very bad
indeed ; but the itching finally got less, and the patient eventually re-
covered.

Joseph1 believes that some of these cases of idiopathic pruritus are
due to disease of the cutaneous nerve endings, the Pacinian and Meiss-
ner corpuscles themselves, though he admits that there is as yet no
histological proof of his proposition. Others, of course, are due to
disturbances of metabolism. He reiterates his belief in the efficacy of
bromocoll. I have used it in a good many cases, and I cannot say
that I have had much success with it. It may be tried, however, when
other remedies fail, as they not infrequently will.

Leo2 records a case of a male adult who suffered from excruciating
general pruritus, for which there was no ascertainable cause. As his
urine was very alkaline and contained an excess of earthy phosphates,
he was put on hydrochloric acid internally. This lessened the urinary
turbidity, but did not change the urinary reaction or improve the pru-
ritus. Then sulphuric acid in gradually increasing doses was adminis-
tered until the urine became acid. On the eighth day of this treatment
the pruritus ceased. Leo has obtained similar results in other cases,
even when the urine was not alkaline. De Castle3 employs lactic acid
internally, using a 1 per cent, solution, and giving 15 minims of the
acid daily to adults in divided doses, and in proportional doses to
children. In two obstinate and intractable cases of pruritus ani
Rochet4 resected the nerve with permanent relief. In the first, a
female, the pubic nerve was resected ; the second was a male, and the
perineal branch of the lesser sciatic was attacked. Johns5 claims re-
markable results from simple measures in this obstinate affection. He
had the anus carefully cleansed after each defecation, the parts dried
with cotton, and calomel applied. The internal treatment consisted
only of the administration of Epsom salts. He states that he has cured
every case, including one of forty years' standing. It would be very
satisfactory if we all could get similar results.

1 Wiener klinische Rundschau, 1903, No. 28.

2 Therapeutic Gazette, May 15, 1903.

3 Journal de Medecine et de Chirurgie; Medical Review of Reviews, September, 1903.

4 Review de Chirurgie, May, 1903. 5 Therapeutic Gazette, May 15, 1903.

1 2 < DERMA TOLOO Y AND SYPHILIS.

Two elaborate articles od the treatment of pruritus have been written
by Branson1 and Labusquiere.2 Bronson regards menthol as the most
generally useful local antipruritic. It is not anaesthetic, but it relieves
the itching by substituting disturbance of the temperature sense for it.
It may be used in ointment, oil, or powder, but it is best applied in

2 to 4 per cent, alcoholic solution or in cologne-water. This is to be
used freely ; he directs the patient to take the bottle to bed, and sop
the parts with the solution wheu necessary. Thymol or chloroform
may be added to the solution ; it sometimes improves its efficiency,
especially when the skin shows a tendency to the development of urti-
carial lesions. Cutaneous anaesthetics are often efficacious. Hot water
for prolonged periods is excellent, especially for pruritus genitalia and
ani. Camphor, hydrocyanic acid, and potassium cyanide often do well.
Opium, belladonna, stramonium, cocaine, and orthoform are almost inert
on the intact epidermis, and are of little use. Mercuric chloride and
carbolic acid are antipruritic, probably by impeding molecular motion
in the excited nerves. Carbolic acid is probably the most reliable of all
the antipruritics. It should be used stronger than is the general cus-
tom ; there is no danger of absorption if it is properly applied. It
should be used in combination with a drying oil, the keratoplastic effect
of which offsets the keratolitic action of the acid, and a little caustic
potash to emulsify the oil and excite its anticatarrhal effects. Bronson
recommends :

R — Liquor potassse 1 drachm.

Acid, carbolic 2 drachms.

01. lini . . . . . . ad 1 ounce.

01. verbense 2 drops.

This is a 25 per cent, solution, and should be applied once daily,
preferably at night. If the area to which it is to be applied is very
large, it should be diluted. The itching of the toxic urticarias requires
emetics, purgatives, and restricted diet. Senile pruritus should be
treated with general stimulation of the skin with faradism, and cannabis
indica and strychnine internally. Winter pruritus requires attention to
the digestion and the general nutrition and the avoidance of alcoholics
more than anything else. The cause of pruritus genitalia is usually
lithremia, neurasthenia, diabetes, etc. Carbolic acid and hot water do
better in these than in any other cases.

Labusquiere3 discusses the general treatment of the constitutional con-
ditions, diabetes, gout, albuminuria, pregnancy, puerperium, and the
menopause, that frequently occasion pruritus, as well as local lesions,

1 Medical News, April 18, 1903.

* Annales de Therapeutique Dermatologique et Syphiligraphique, iii., Nos. 2 and 3.

' Loc. cit.

DERMATOLOGY. 129

such as vaginitis, metritis, urethral polypus, hemorrhoids, kraurosis, etc.
His favorite internal remedy is quinine valerianate 0.2, antipyrin 0.5,
and sodium bicarbonate 0.25, in a capsule t. d. Locally he employs
Tarnier's formula : hydrargyrum bichloride 2, alcohol 13, aqua rosa?
40, aqua destillat. 450. To be applied twice daily after cleansing the
parts.

Pemphigus Neonatorum. A number of articles on this subject
have appeared during the year. Adamson1 cannot have seen very
many of these cases, for he holds them all to be merely a variety of
impetigo contagiosa, and due to streptococcus infection. Ostermeyer's2
views are much more in accord with my own. He distinguishes three
kinds of bullous eruption in the newborn :

1. Pemphigus neonatorum benignus, a variety of impetigo contagiosa.

2. Pemphigus neonatorum malignus, a true pemphigus.

3. Pemphigus neonatorum syphiliticus, which is heredosyphilis.
Cases in the first category always recover, those of the second almost

invariably die, and with those in the third the prognosis is doubtful and
largely dependent on the efficiency of the treatment. I know of no
way to distinguish these cases from one another with certainty in their
beginning. Syphilis in the parents, of course, favors the existence of
lues, and the presence of lesions on the palms and soles renders the
diagnosis almost positive. When these are not present I am in the
habit of advising a temporizing policy for a few days. The advent of
fever and other constitutional symptoms will clear the diagnosis.

Magurie3 records an epidemic of eighteen cases of acute contagious
pemphigus neonatorum, many of which were fatal, and in which treat-
ment seemed to have but little effect. They were spread by a mid wife,
and the point of entrance of the virus was the navel. The cause was
the staphylococcus pyogenes aureus. On the other hand, Whitfield4
believes with Balzer and Griffon, Sabouroud, Gilchrist, and others that
the streptococcus and not the staphylococcus is the etiological factor in
these cases. Of his two cases one appeared on the seventeenth day of
life ; and one bulla came on the mother's forehead. I have more than
once seen the mother infected in this way ; and the point is important,
since the presence of maternal skin lesions is liable to lead to an erro-
neous diagnosis of syphilis. This case, in which the fluid from the
bullae gave almost pure streptococcus cultures, recovered. In the second
case the eruption appeared on the tenth day, and was general ; the case
ended fatally. Pasini/' on the basis of an epidemic of the disease that

1 Dermatologisches Centralblatt, February, 1904.

1 Ibid. 3 Ibid.

4 British Journal of Dermatology, June, 1903.

5 Oiornale italiano delle malattie veneree e della pelle, Milan, 1903, No. 3

130 DERMATOLOGY AND SYTHILIS.

he observed, believes that it is occasioned by a special diplococcus, the
diplococcus pemphigi neonatorum, which may be mild or septic in its

effects.

1 am inclined to classify the milder isolated cases that recover as
instances of contagious impetigo, and the epidemic and severer ones as
true pemphigus. As I have said before, the entire subject of the bul-
lous dermatites is in a somewhat chaotic condition, and urgently needs
thorough investigation.

Psoriasis. The pathogenesis of this affection has been further studied
during the past year, without, however, any important addition to our
knowledge of the subject. Attention has been called in previous reviews1
to the varying opinions as to its origin in a microbic invasion, in inter-
nal causes, and even from mental effect. Verotti2 claims that it is due
to autointoxication by the organic acids, the activity of the psoriatic
process being in direct relationship to the acidity of the blood and the
urine, and in converse relationship to the functional activity of the kid-
neys. He therefore advises an alkaline internal treatment. Orlipski,3
on the other hand, believes that some cases, at all events, are caused by
the entrance of an organic causative factor through the trauma. He
recounts the history of a case that began at an abrasion caused by a fall.

The more unusual aspects of the disease have been studied by Bur-
gener.4 Psoriasis buccalis he regards as frequent, and claims to have
had the extraordinay number of 160 cases. Probably he placed all his
leukoplakias in the psoriatic category. Psoriasis of the nails occurs in
a proportion of cases that is differently estimated by various observers ;
the extremes are Jadassohn 21 per cent., and Heller 5.26 per cent.
Biirgeuer believes that a mean of 9 per cent, between these figures is
probably a correct statement of the frequency of nail involvement in
this disease. There is no absolutely unequivocal case of psoriasis of
the nails alone on record, though there are some in which the nails
have been first affected. As a matter of fact, there are no positive cri-
teria for making the diagnosis in the absence of lesions on other parts
of the body. I have seen more than one case that I have regarded as
psoriasis unguium, but have felt unable to make an absolute diagnosis.
Psoriasis of the palms and soles is not very uncommon. Yet in my
student days we were taught that it never occurred, and that palmar
psoriasis always meant syphilis. I have seen at least 4 cases of un-

1 Progressive Medicine, September, 1901, p. 189 ; September, 1902, p. 189 ; Sep-
tember, 1803, p. 155.

2 Giornale italiano delta scienc. med. ; Monatshefte f. praktische Dermatologie,
May 1, 1903.

3 Die medicinische Wochen. ; Monatshefte f. praktische Dermatologie, May 1, 1903.
* Deutsche Medicinal-Zeitung, 1903, Nos. 1 and 3.

DERMATOLOGY. 131

doubted psoriasis of the palms daring the last year ; in 1 of these there
were no spots elsewhere until long after. Biirgener found 44 out of
170 cases, or 26 per cent., thus affected; again an extraordinary large
proportion. As regards the presence of diabetes, he found it only twice
in 230 cases, and then it was probably accidental. Watts'1 observa-
tion of a case of palmar psoriasis was interesting, as it occurred in his
own person, and he has had neither acquired nor heredosyphilis. That
many of the recorded cases of buccal psoriasis are really leukoplakias
of syphilitic or other origin is the opinion of Oppenheim,2 and I entirely
agree with him. Further cases have been recorded by Marcel See3
and others, but in every case there were general dermal in addition to
the mouth lesions.

I have of late years been using the tar preparations more and more in
the place of chrysarobin in the treatment of psoriasis. It has a less
deleterious effect on the skin and the linen, especially if the rectified
birch tar is used, and is almost as efficacious. Dreuw,4 writing from
Unna's clinic, recommends the following: salicylic acid, 10; chrysa-
robin, ol. rusci, an 20 ; green soap and vaselin, aa 25 parts. This is
to be applied twice a day with a bristle-brush for three or four days.
Then a black layer forms on the plaques, which is to be removed with
green soap and hot water, or with benzin. Myelocene is employed
externally by Watson f the bone-marrow is applied in a 30 per cent,
oil. Thyroid is pretty well discredited as a psoriasis remedy, but Eng-
lish6 claims to have cured a case with it. Leslie Phillips7 has been
experimenting with hydroxylamin in the place of chrysarobin and pyro-
gallol ; he finds that it has no special advantages over these substances,
and while it does not discolor the skin, it is volatile, and may cause
hsematuria. Truffi8 rejects the 1 per cent, potassium permanganate
treatment as ineffective.

A very extensive case of psoriasis that was under my charge this
winter is shown in Fig. 10.

Radium in Dermatology. It is almost too soon to chronicle any
results in dermal therapeutics for the radioactive substance to which
public attention has been drawn so much of late ; and our experiences
in the very recent radiotherapeutic epidemic are still so fresh that
we are inclined to take a most conservative attitude toward wonder-

1 British Medical Journal, March 28, 1903.

2 Dermatologisches Centralblatt, February, 1904.

3 Annales de Dermatologie et de Syphiligraphie, March, 1903.
* Dermatologisches Centralblatt, August, 1903.

5 Lancet ; Monatshefte f. praktische Dermatologie, May 1, 1903.

« ibid. 7 British Medical Journal, March 7, 1903.

8 Gazz. med. Lomb. ; Monatshefte f. praktische Dermatologie, July 15, 1903.

132

DERMATOLOGY AND SYPHILIS.

working novelties. We note, however, that Holtzknecht1 has used
radium in several cases, giving only one application to each. A gyrate
psoriasis which had been nearly cured (as in most cases) by radio-
therapy was completely removed by radium. The author claims that

Fig. L9.

Diffuse psoriasis. (Author's case.)

one minute's application is sufficient to cure psoriasis. In hypertrophic
lupus, also, there was a good result. Epithelioma of the cheek " sub-
sided " after three five-minute applications of a radium capsule. Re-

1 Monatshefte f. praktische Dermatologie, November 1, 1903.

DERMATOLOGY 133

markable results were also achieved in an extensive telangiectasis affect-
ing the entire left arm.

Holtzknecht gives the details in his article of the exceedingly simple
manner in which the treatment is carried out. Thinnest sheets and
smallest amounts of the radioactive substances only are required. It
is especially applicable to the treatment of cavities where other methods
cannot be employed. There is but little penetration, as 99 per cent, of
the total energy is lost. In the discussion of this paper at the eighth
congress of the German Dermatological Society at Sarajewo, Peleran,
Neisser, Pick, and Widenfeld all sounded a warning as regards the
danger of causing ulceration and sloughing by the use of these agents.
F. H. Williams1 states that he has gotten excellent results in epithe-
lioma from them, and also in lupus ; in eczema and psoriasis he finds
them of no avail. In a general way their effects are the same as those
of the Roentgen ray, but more intense.

Radiotherapy and Radiodermatitis. The recorded results of the
year sustain the position that I have taken in previous reviews as to the
efficacy of the Roentgen treatment of dermatoses. Among the many
articles that have appeared some are by enthusiastic advocates of the
method ; but a more conservative attitude on the part of those best
qualified to judge is very evident. Bronson, in a very thorough review
of the subject at the American Therapeutic Association, Washington,
May 12, 1903, says that radiotherapy is of great value, at least as an
adjuvant to other things, but that in very few cases does it supplant the
older treatments. No treatment requires greater circumspection in its
use, or a nicer adjustment of details. Burns2 finds it very useful in
epithelioma, though the permanency of the cures is still open to question.
A full account of the various dermal affections in which good results
are claimed will be found in last year's review.3

That the method is an entire failure in many cases of epithelioma and
rodent ulcer is undoubted. 1 have met several during the winter which
had had scores of sessions at the hands of well-qualified operators. One
or two were distinctly made worse : and in all cases there was evidently
some damage done to the skin and subcutaneous tissues. They reacted
peculiarly to instrumental and other interference ; healing was excep-
tionally prolonged, taking many times the usual period, and the impres-
sion of all who saw them was that they had suffered from some deep-
seated and vitality depressing injury. Blum4 calls attention to the
abuse of radiotherapy apropos of two cases of bromoderma and palmar

1 Medical News, February, 1904.

2 Boston Medical and Surgical Journal, October 29, 1903.

3 Progressive Medicine, September, 1903, p. 158.

4 Louisville Journal of Medicine and Surgery, July, 1903.

134 DERMATOLOGY AND SYPHILIS.

syphilide in which ulceration had been occasioned by it. In the discus-
sion on his paper at the Louisville Surgical Society Butler defended
the .r-ray, taking- the ground that it should be employed in all cases of
skin disease in which the diagnosis was not certain. This is unfortu-
nately the position taken by many .r-ray workers.

Bessemer1 reports a ease of fatal sepsis from an a--ray burn. Kiim-
mell. in the discussion on that subject at the Thirty-second Congress
of the German Surgical Society, mentioned a case in which the ulcera-
tion from raying became cancerous, and amputation of the limb was
required. I have recorded a similar case.2 Holtzknecht3 has had five
cases of radiodermatitis with general symptoms — fever, eruption, etc.
He believes them to have been due to toxin production and absorption
in the burned skin, similar to what occurs in ordinary burns. Schmidt
had a case in which acute atrophy of the skin followed the radioder-
matitis.

I can hardly agree with him in his classification of the acute dermic
atrophy as " idiopathic/5

It is needless to multiply instances. One of our best known derma-
tologists, who has used the .r-ray as much as anyone in his specialty,
admitted to me that he did not regard an #-ray machine as a necessary
part of the dermatologists' armamentarium. There were perhaps one
or two conditions in which results unattainable by other methods could
be gotten by it, but hardly anywhere did it replace the older methods.
I would go much farther. In many cases radiotherapy is decidedly
inferior to other methods. None but an enthusiast would advocate its
indiscriminate use in eczema and psoriasis. I am sure we have much
better success with the curette and caustic in the various forms of skin
cancer. And even in lupus and the tuberculoses of the skin it is more
than doubtful if it can hold its own with the light treatment.

Sarcoma Cutis. This subject was considered at some length in the
last twTo reviews.4 Reale5 has made some experiments as regards the
inoculability of this affection. He placed a fragment from a true pig-
mented sarcoma of the Kaposi type under the skin of a rabbit. A
nodule remained, but there was no other effect. In the third year
after it began to grow, and became as large as a chestnut. It was then
excised and examined ; it w-as found to be an endothelial sarcoma,
apparently originating from the lymphatic endothelium. The exact
microscopic diagnosis was lymphoangiosarcoma.

1 New York State Journal of Medicine, July, 1903.

2 Progressive Medicine, September, 1901, p. 161.

3 Derrnatologisches Centralblatt, October, 1903.

4 Progressive Medicine, September, 1902, p. 196, and September, 1903, p. 162.

5 Annales de Dermatologie et de Syphiligraphie, October, 1903.

DERMATOLOGY. 1 3 5

Wende1 has made a thorough study of one variety of this affection,
and comes to the following conclusion :

1. Sarcomatosis cutis of the Kaposi type, with sarcoid tumors, is a
distinct disease.

2. It occurs especially in the young. (This is not my own or the
general experience. — G.). The initial lesion is a small, deep-seated
papule, growing to a certain size, suppurating, or becoming exuberant.
(I have found fatty degeneration and interstitial absorption a commoner
termination. — G.).

3. Histologically there is a round-celled infiltration in the deeper
layers of the skin, around the vessels, hair follicles, sebaceous glands,
and lymphatic spaces. Their etiology is dark; they are probably due
to infection.

4. The microscopic findings are like those of mycosis fungoides. But
the clinical picture is different. Syphilis, lymphodermia, blastomycosis,
and carcinomatosis cutis are histologically different.

5. Spontaneous disappearance of the tumors occurs. There are no
lymph nodes or metastases. It remains exclusively a skin disease. It
is therefore rather to be classed as a granuloma than as a true neoplasm.

Sellei2 also believes the tumors in these cases to be those of a chronic
inflammatory granuloma rather than a true sarcoma. There are fibro-
blasts, large numbers of plasma cells, leukocytes, lymphocytes, mast
cells, and new vessels. This is not the histology of a sarcoma. Bern-
hardt,3 however, basing his conclusions on a study of three cases of the
Kaposi type, inclines to the belief that they are angiosarcomata. I
agree with him. I have had an opportunity to study several of these
cases very carefully, and have recorded my results.4 I could not micro-
scopically detect any essential differences between these lesions and
those of undoubted small round-celled sarcoma.

Suprarenal Extract in Dermatoses. Engman and Loth5 have used
suprarenal in toxic dermatoses, showing derangement of the vessels or of
the nerves controlling them. In some instances the drug is almost a
specific ; but it is useless when there is chronic inflammation or an exuda-
tion of cellular elements. There was marked benefit in general pruritus.
In chronic urticaria four cases were entirely relieved by 5-grain doses
t. d., without any other treatment. It at once relieved the pruritus and
prevented the formation of wheals. In eight cases of lichen urticatus
there was complete success. In two cases of morphcea there were also

1 Journal of Cutaneous Diseases, June, 1903.

7 Archiv f. Dermatologie u. Syphilis, 1903, Bd. lxvi. p. 40.

3 British Journal of Dermatology, June, 1903.

4 Journal of Cutaneous Diseases, June, 1902.

5 Therapeutic Gazette, July 15, 1903.

136 DERMATOLOGY AND SYPHILIS.

satisfactory results. The authors usually employed the dry powdered
extract. Too free administration caused nausea, dizziness, and acute
tremor. ( hildren of four years took 1 \ to 2 grains t. d. without trouble ;
adults "J to I) grains t. d. The drug should never be given on an empty
stomach, as it then causes purging, griping, nausea, and vomiting from its
local effect. There seems to be a cumulative effect on the nervous system ;
it should therefore not be taken for more than one month. I propose
to give the treatment a thorough trial in some of these obstinate cases.

Trichophytosis. The main interest in this disease centres on the
cases in which the head or beard is affected ; ringworm of the non-
hairy parts is curable by the simplest measures. Those of us who
have had professional charge of orphan asylums or reformatories or any
institution where large numbers of children are lodged together, and
where the impossibility of curing some of the cases and of completely
eradicating the disease has been brought home to us, will appreciate its
importance. In view of. its frequency in this country, a statement re-
cently made by Joseph1 is surprising. It is so rare in Germany that
he has seen only four cases in his polyclinic in years, and only three in
the hospital during the same time.

Hodara2 sticks to chrysarobin, which is, of course, an approved
remedy for the affection. The affected area is shaved, and a 5 to 10
per cent, chrysarobin solution in chloroform and glycerin painted on
once or twice daily for four days or more. The application is stopped
when the redness and swelling become marked, and olive oil is applied
until these symptoms subside. Then treatment is begun again. The
time required for cure is four to five months.

The objection to chrysarobin is that, like iodine, it stains the affected
area deeply, and prevents our seeing the condition of the skin and hairs.
I therefore prefer the colorless mercurial preparations, especially as I
believe that epilation should be employed in many cases.

Croton oil and pure formalin (40 per cent, aqueous formaldehyde
solution) will cure affected patches quickly, but they cause destruction
of tissue ; a scar and permanent alopecia result. I do not think their
use permissible save when there is only a single small patch of the dis-
ease, or where, for one reason or another, a rapid cure, even at the
expense of tissue destruction, is required.

In the review of two years ago3 I described the method that was
employed at an orphan asylum where George H. Fox and I were the
dermatological consultants. I have since reviewed the entire epidemic.4

1 Centralblatt f. Kinderheilkunde, 1903, No. 2.

2 Monatshefte f. praktische Dermatologie, November 15, 1903.

3 Progressive Medicine, September, 1902, p. 200.

4 Medical News, September, 1903.

DERMATOLOGY. 137

There were 460 cases of scalp disease in 900 children, and a large pro-
portion of them had deep infection and kerion. In the overcrowded
institution it was a matter of extreme difficulty to institute and keep up
efficient treatment. "With the aid of a number of assistants and a large
staff of nurses this was finally effected, and a bacteriological laboratory
was established for the purpose of controlling the cures. A barber was
permanently employed to keep the affected heads close shaven. Epila-
tion was, of course, impracticable in so large a number of extensive
cases, and was employed only on isolated patches in special instances.
One hundred and fifty of the infected girls were transferred to my der-
matological service at Lebanon Hospital, where an efficient house and
nursing staff were at my disposal.

The patients were divided into sections, and put on many various
forms of treatment, including chrysarobin, formalin, croton oil, diluted
bichloride of mercury, carbolic acid, iodine, and sublamin. Unfortu-
nately, with all our efforts, it was impossible to keep accurate track of
the cases and histories of the results obtained.

Chrysarobin was soon abandoned, for not only did the staining of the
tissues interfere with the necessarily rapid examinations which the
assistant physicians had to make daily, but it was also found impossible
to keep the children from getting it into their faces and eyes. Iodine
was rejected on account of its staining. No definite results were ob-
tained from the use of salicylic acid in any form or concentration, and
its use was abandoned after a time. The same is true of carbolic acid,
which was used pure, alcohol being applied after it. Formalin in 10
per cent, solution was well borne, but did not seem to effect any very
great change in the patches. We finally came down to three drugs
only, the bichloride, sublamin, and croton oil.

The first of these was usually employed in 1 : 1000 solution; this
was found too strong, however, for use twice daily in many cases, and
it had to be weakened to 1 : 2000. It seemed deficient in penetrative
power also, and many cases after prolonged treatment had obstinate
patches left which had to be treated with croton oil. The organic mer-
curial compound, on the other hand, could be used in all cases in 1 •: 1000
solution ; in obstinate cases a 1 : 750 solution gave us no trouble.
Stronger than that we found sublamin irritant, in spite of the claims
made for it. Croton oil in 33 per cent, oily solution was used for re-
calcitrant patches. It was applied several times in succession until a
vigorous reaction took place. Then an ordinary soothing application
(usually 3 per cent, salicylated oil) was employed until the inflamma-
tion subsided, when the regular treatment was resumed.

As the result of my experience in this and other epidemics I think
I can make the following statements as regards the handling of them :

138 DEH MA TO LOO Y AND S Y PHIL IS.

1. Epilation, while it is a, measure of the greatest efficiency in the
treatment of individual eases of ringworm of the scalp, cannot be used
where Large numbers of cases have to be treated. Its place must be
taken by shaving the scalp, which should be done once a week.

•J. Scrubbing the head with green soap and hot water twice daily
before applying the parasiticide is of the greatest importance.

.!. This latter must be thoroughly nibbed into the scalp twice daily
with a brush. A remedy that does not stain, the bichloride or, prefer-
ably, sublamine in 1 : L000 solution, is the best that we can employ.

4. Croton oil is to be reserved for obstinate local patches.

.">. Institution cases can only be regarded as positively cured when
there are no macroscopic evidences of disease three weeks after cessa-
tion of treatment ; and microscopic examination of the hair shows
absence of the fungi. The bacterioscopic test is not reliable, since
experience shows that fungi indistinguishable from the pathogenic ones
can be cultivated from apparently healthy heads in institution epi-
demics.

6. The most stringent measures are required for the protection of
the healthy children and the prevention of the spread of the epidemic.
These have already been detailed in the 1902 review.1

SYPHILIS.

The Antiquity of Syphilis. I have elsewhere expressed my belief
that the records of the appearance of syphilis de novo in the fifteenth
century were erroneous. A cogent argument for this view is the sud-
den disappearance of leprosy at the same time. Europe and Asia were
full of leprosy, and in the former leper-houses abounded. Yet it ap-
parently disappeared suddenly when syphilis began to be recognized,
and to such an extent that the malady was forgotten, and was practically
rediscovered in the nineteenth century. For this, among other reasons,
it seems very probable that syphilis and lepra were confounded by the
older observers. The renaissance stimulated intercommunication and
the spread of knowledge, and the luetic epidemic that spread over the
civilized world at that time was recognized as a distinct disease due to
venereal infection. But syphilis was not new, and leprosy did not die
out ; modern investigation is continually giving us fresh proofs of the
truth of these two propositions. Lepers have been found in all quar-
ters of the globe, and where records of any kind can be found it seems
always to have been present. A very recent investigator, on a con-

1 Progressive Medicine, September, 1902, p. 200.

SYPHILIS. 139

servative estimate, places the whole number of lepers in the world as at
least 300,00c1

On the other hand, evidences of the antiquity of syphilis have been
found in many ancient writings and remains. The latest comes from
Japan, where Adachi2 has found characteristic lesions in bones in a
shell-fish heap dating from the stone age, and at least thousands of
years old. Syphilis could not, therefore, have been introduced into the
islands in the sixteenth century, as some writers claim.

Syphilis in Animals. A main hinderance to the advance of our
knowledge of the luetic disease has been the impossibility of animal
experimentation ; hence attempts to inoculate the disease in the lower
animals has been unremitting. An account of some recent experiments
in that direction has already been given.3 Since then a number of
observations have been recorded. At the Seventy-fifth Congress of
German Naturalists and Physicians at Cassell, September 20, 1903,
Friedenthal1 showed pictures of two apes with bullous palmar erup-
tions after inoculation with chancrous tissue. The animals also had
multiple adenopathies ; but fortunately both of them died very quickly.
Metchnikoff,5 in Paris, has tried similar experiments, and has succeeded
in producing an initial lesion in an ape by inoculation from secondary
human lesions which Fournier pronounced to be typical. The cost of
such experimentation is enormous and almost prohibitive ; the smaller
apes have proved recalcitrant, and anthropoids, most nearly related to the
human species, and costing $1800 apiece, have to be employed. A
chimpanzee died fourteen weeks after inoculation from lung disease ; a
female inoculated from this one showed specific syphilitic lesions, but
soon died in the same way. There were no specific lesions in the first
animal. Lassar6 repeated these experiments on a chimpanzee. Most
of the inoculated points healed quickly. Two ulcers developed on the
brow, which slowly retrogressed in the course of a few weeks. There
were some palmar and plantar papules. Lassar's critique of his work
contains the pregnant statement that it requires considerable good-will
to regard these symptoms as positive evidences of syphilitic infection. We
can sum up the whole matter with the Scotch verdict of " not proven."
The Syphilis Bacilli. The amount of work that has been done in
the last thirty-five years in the search for the organic agent that causes

1 Filare"topoulo, Dermatologisches Centralblatt, May, 1903.

2 Dermatologisches Centralblatt, May, 1903.

s Progressive Medicine, September, 1902, p. 203.

* Monatshefte f. praktische Dermatologie, November 1, 1903.

5 Deutsche Medicinische Wochenschrift ; Journal of the American Medical Associ-
ation, January 9, 1904

6 Berliner klinische Wochenschrift; Journal of the American Medical Association,
February 20, 1904.

14Q DERMATOLOGY AND SYPHILIS.

the syphilitic infection is enormous. Organisms of all kinds have been
found and triumphantly exhibited as the real specific germ, in every
case, however, cither to have the claims made for them quickly dis-
proved or to become acknowledged failures by the absence of confirma-
tion. Thus as long ago as 1869 Hallin found a " specific" micrococcus
in the red blood cells, and Klotsch characteristic spores in the blood
and the skin lesions. The year 1870 gave us Salisbury and Briihlkens
with their " ervpta syphilitica," Klebs with his coccobacillus, with
which he infected monkeys, and Lostorfer with his syphilitic corpus-
cles; and Klebs' discovery was apparently confirmed by Berman. In
L878 Cutter found a mycelium, and in 1881 Aufrecht and Obraszow
found a micrococcus or diplococcus; 1882 was marked by the cocci of
Birch-Hirschfeld and Peschal, with which Martineau is said to have
successfully inoculated hogs and monkeys. In 1883 Kobner and Neu-
man found a micrococcus, but could not inoculate it; in 1884 the Lust-
garten bacillus was described, and the finding was confirmed by De
Michale and Radue, and by Doutrelepont and Schutz in that year, as
also by De Giacomo and Gottstein in the year following. Sabouraud,
in 1892, failed to find the Lustgarten bacillus. Von Neissen, in 1898,
proclaimed a streptobacillus as the long sought-for organism, and has
been persistently advocating its claims ever since. Mention has been
made in previous reviews1 of the bacillus of De Lille and Julien, and
the still more recent bacillus of Joseph and Piorkowski and the pro-
tozoa of Schiiller.

There has been no cessation in the search during the past year.
Schiiller2 again claims that his protozoa-like parasites are always found
in hard chancres, and holds that they have an undoubted relationship
to the syphilitic processes, though he admits that its exact nature is
still undetermined. Waelsch,3 in an elaborate article on the subject,
states that he has found the von Neissen bacillus in sixteen out of
thirty-five cases of florid syphilis, being 45 per cent, of the cases ; the
discoverer found the organism in every case. But Waelsch4 also found
the microbe in non-syphilitics, and proves pretty conclusively that it is
an accidental finding. He examined seventy-seven cases, including
sclerosis, indurated glands, secretion from anginas, etc., and cerebrospinal
fluids. Inoculation experiments on rabbits and guinea-pigs were nega-
tive ; pigs and apes showed an exanthem eight weeks later. He re-
gards the organism as the pseudodiphtheria bacillus. Similar results
were obtained by von Buchta and Winternitz. Pini found the Jul-

1 Progressive Medicine, September, 1901, p. 203 ; September, 1902, p. 206.
* Monatshefte f. praktische Dermatologie, November 1, 1903.

3 Archiv f. Dermatologie u. Syphilis, January, 1904.

4 Monatshefte f. praktische Dermatologie, November 1, 1903.

SYPHILIS.

141

lien-de-Lile organism in some cases,1 but attempts at human inoculation
were negative, and he denies the specific nature of the microbe.

Apparently the criticism editorially made in the Journal of the Amer-
ican Medical Association is a just one.2 Those who seek for organisms
seem to find them. The real organic cause of the specific disease is
still unknown to us.

The Prognosis of Syphilis. I have long been of the opinion that
this is regarded as more unfavorable than is really the case by most

Fig. 20.

fe K-

*" - , \m

s ■ 1 ■

§

r

v -

\

Ulcerated gumma. (Author's case.)

practitioners. Their views are derived from medical traditions founded
on syphilis as it was in the past ; and they are strengthened by a few
extremists among syphilographers, who claim that the disease once con-
tracted can never be cured. It is very certain that the lues that we see

1 Giornale italiano delle malattie veneree e della pelle, Milan ; Monatshefte f. prak-
tische Dermatologie, April 1, 1903.

2 Journal of the American Medical Association, July 25, 1900.

142 DERMATOLOGY AND SYPHILIS.

to-day is in the great majority of cases a comparatively mild and tract-
able disease. The change from the malignant type that was common
in the disease since the great European outbreak of the fifteenth and
sixteenth eentnries has Ween a gradual one ; but it has apparently been
more rapid of recent years. Certain it is, and in this view I am sus-
tained by others, that severe types of the disease are decreasing in fre-
quency. Even those of us whose experience reaches no farther back
than twenty years are impressed with the fact. The extensive gum-
matous ulcerations, the tubercular, pustular, and ulcerative exanthems,
the serious affections of the mucous membranes, and the phagadenic
and necrosing scleroses are less common in the City (Charity) Hospital
to-day than they were when I was interne there in 1883 ; they are still
seen occasionally, however, as a case of gumma in my service at the
hospital last summer shows (Fig. 20). In the ambulant dispensary and
private practice the change is very marked. Most of my photographs
of severe syphilis date from years ago, and true malignant lues is now
but rarely seen.

As regards the curability of syphilis, 1 hold the prognosis to be in
o-eneral very good. I have elsewhere1 stated my position on this ques-
tion in full. It is, after all, a question of definition of the term " cure."

If we mean by that word an absolute certainty that there will never
be at any time any after-effects or sequela? from the infection that has
been sustained, then, of course, there is no enre. But if we mean that
the active course of the disease is ended, that it can no longer be inocu-
lated upon others or transmitted to offspring, that the patient remains
immune to future infection, and that there is little likelihood of his
suffering from any manifestation of the disease, then syphilis can be
cured. The great majority of our cases, more especially those that
have been properly treated, show no further symptoms of the disease,
either in themselves or in their offspring. The very rarity of the ter-
tiary manifestations is a proof that most of the cases are cured. The
estimates of various investigators place their occurrence at from 4 to 40
per cent, I think 10 per cent, would be a fair statement of their fre-
quency. Adding another 10 per cent, for the frequency of occurrence
of heredotransmission (a liberal figure), it is apparent that four out of
every five cases are cured. My conclusions are as follows :

1. Svphilis is a curable disease, and may even, with restrictions, be
called a self-limited one.

2. While cure in a given case can never be affirmed with scientific
accuracy, the chances of such being the case after a certain time under
proper treatment are so great that it may properly be claimed to have
been effected.

1 Syphilis, A Symposium. Treat, New York, 1902, p. 89.

SYPHILIS. 143

3. Practically, a patient who has been properly treated through the
active stages of his disease, and who has had no manifestations of it for
several years thereafter, may be regarded as cured, and may be told so.

Bloom's conclusions as to the prognosis of the disease are very simi-
lar.1 They are :

1. The largest proportion of those treated at the beginning of the
attack by the prevailing methods get well in two to four years, without
the development of the severer and later forms of the disease.

2. A small number, iu spite of the most favorable circumstances and
the best treatment, develop late symptoms requiring further treatment,
and usually yielding readily to it.

3. Alcoholics, neurotics, and tuberculous patients are very prone to
have the later severer syphilides.

4. Cases untreated or only treated late are apt to show severe and
intractable symptoms.

5. Inefficient treatment, either in amount or duration, is often fol-
lowed by severe sequela?.

6. A very small number get well without treatment.

There are points in the above that I would modify, but in a general
way Bloom's conclusions are the same as my own. I take a decided
stand in favor not only of the curability of ordinary syphilis, but also
of its general mildness and tractability as we meet with it to-day.

Syphilis as a Life Shortener. At a meeting of the Paris Academy
of Medicine Fournier2 discussed the subject of syphilis and suicide.
He said that he had seen not less than eighteen suicides as the direct
result of the infection, which he divided into four groups :

1. Patients with active syphilis with cerebral localizations, delirium,
madness, etc.

2. Patients insufficiently or badly treated, and suffering from mental
depression.

3. Patients to whom the physician had brusquely told all the dan-
gerous possibilities of the disease.

4. Patients about to be married, etc.

Fournier rightly believes that we can do a great deal for the latter
two classes, and I would emphasize the importance of making a hopeful
prognosis. I have recorded my views on the subject in the last section.
The laity and many practitioners take too gloomy a view of the affection.
The gonorrhoeic patient at his first visit asks how soon he can be cured ;
the syphilitic whether he can be cured at all. Even if the prospect of
cure was not good I think it would be our duty to encourage the sufferer

1 Louisville Monthly Journal of Medicine and Surgery, November, 1903.

2 Le Progres Medical ; Medical Bulletin, July, 1903.

144 DERMATOLOGY AND S Y PHIL IS.

and to give him the benefit of hope. As I hold the general prognosis
to be favorable, 1 do not hesitate to tell my patients as a usual thing that
they will certainly be cured, provided they obey directions and have
proper treatment for the requisite period of time.

Nevertheless, the stand taken by the life insurance companies is that
syphilis does, on the whole, shorten life. Bramwell1 says that even a
strong man who has had it is not a first-class risk, and should have an
extra premium imposed. He holds that only a small part of the real
tertiary syphilis mortality is recognized ; that many cases of aortitis,
aortic aneurysm, paralysis of the insane, tabes, cirrhosis of the liver, etc.,
are due to it. I cannot unreservedly agree with him when he states that
75 per cent, of all tabes cases are due to syphilis; that is a matter that
is still su/> jiitJice. In seventeen out of thirty-two fatal tabes cases in
which exact data of the specific infection were obtained, Bramwell found
that the life expectancy was diminished two hundred and seventy years.
He also claims that three-fourths of the cases of general paralysis of
the insane are due to the infection, and that a study of the Scottish
Widows' Fund shows that the average life expectancy is shortened
twenty years in these cases.

I agree with Martin2 very thoroughly in his expression of doubt as to
the validity of Bramwell's conclusions. I believe that he overestimates
the role of the luetic infection in the disease in question ; the fact that
a patient has had syphilis is not necessarily a proof of its being their
cause. Graham Brown3 takes a different position. He says that a well
individual in whom the infection is four years or more past, and who
has been properly treated, can be taken as a risk at a slight increase of
the usual rates. In a man aged thirty years he would add five years.
He would reject all cases, however, in which tertiary lesions are present,
and he would require a special certificate from the physician who treated
the syphilis in addition to that of the regular examiner.

The Treatment of Syphilis. Block4 emphasizes the fact that the
lesions of syphilis are due primarily to disease of the vessel walls, simi-
lar to those caused by chronic alcoholism, dissipation, etc., affections of the
other organs, and especially of the nervous system, being caused thereby.
Hence the importance of hygiene, of early going to bed, long hours of
sleep, exercise, nourishing food, baths, etc., and the avoidance of all
debilitating agents, and especially alcohol. I always pay especial atten-
tion to these points in laying down a course of treatment, for I feel cer-

1 Therapeutic Gazette, July 15, 1903. J Editorial. Ibid.

3 Scottish Medical and Surgical Journal; Annales de Dermatologie et de Syphili-
graphie, October, 1903.

4 Zeitschrift f. dietatische u. physikalische Therapie ; Journal of the American Medi-
cal Association, July 4, 1903.

SYPHILIS. 145

tain that the main factor determines the difference between a severe and
a mild syphilis in the general health of the patient. Of course, there
are other factors, and we occasionally see a bad case in a patient other-
wise in flourishing health ; but the general rule holds good, and we can
sometimes do more for our patients by means of these measures than
with the specific medication itself. In fact, the main benefit that accrues,
if any does, from a sojourn at Hot Springs, Aix-la-Chapelle, or similar
places, is due to the change of air, scene, and occupation, and possibly
the improved hygiene that is effected. And here it will not be out of
place to say a word or two in regard to the baths, for, strange to say,
not a few physicians believe in and send their patients to them.

As a matter of fact, the treatment given to the patients at these places
differs in no respect from that ordinarily employed. The baths them-
selves, in spite of the stress laid upon them, are of no especial efficacy.
Neither here nor in Europe do the authorities in the luetic disease reside
at the watering places. Handling patients en masse and schematically,
as is necessarily done there, cannot be in the best interests of patients
suffering from a disease that requires so much therapeutic individualiza-
tion. I have never, in all my experience, had a case that I thought
ought to go to one of them ; some have done so, and have returned im-
proved, unimproved, or worse, just as they would have done if they had
been treated at home. The Hot Springs idea is a superstition which
we should combat by every means in our power.

The year has been especially prolific of articles on the treatment of
syphilis. Von During1 is an opponent of the chronic intermittent treat-
ment of Neisser-Fournier, but he believes in the intramuscular injec-
tions of the salicylate of mercury in large doses (0.08 to 0.1) twice
weekly, till all the symptoms have disappeared, then less frequent
injections may be made. He holds the possibilities of embolism as of no
importance. Price2 advocates a combination of cupric sulphate in one-
tenth grain doses with the mercury. Experience has not shown, I think,
that there is any advantage in departures from the standard drug.
Galewsky3 proposes a soluble calomel, a 1:50 colloidal mixture, which
is neutral and non-irritating, for both injections and inunctions. Iu
the absence of fuller details and personal experience I can give no
opinion on it. Fuller4 pleads for the injection mode of administration,
using a method exactly similar to my own. Lesser5 claims to have had

1 Miinchener medicinische Wochenschrift ; Derinatologisches Centralblatt, March,
1903.

2 Medical Record, October 24, 1903.

3 Monatshefte f. praktische Dermatologie, November 1, 1903.

4 Journal of the American Medical Association, May 7, 1903.

s Therapie der Gegenwart; Journal of the American Medical Association May 7, 1903.

10

146 DERMATOLOGY AND SYPHILIS.

severe intoxications and serious by-effects from them, yet ho rocom
mends calomel injections in severe oases. Bernert1 states that many
so-called incurable cases can be restored to health by the hypodermic
treatment. Schwab2 uses it even in heredosyphilis, and in the new-
horn. He employs an aqueous solution of the biniodide, giving 0.5 mm.
per day. The formula that he uses is : hydrargyrum biniodide,
sodium iodide, aa 0.05 : aqua dest, 10 c.c. The results are excellent.
Tommasoli3 injects the sublimate into the venous circulation, giving
6 to 8 milligrams at a dose. He claims in this way to have practically
aborted a number of cases taken in their earliest stages. Leredde4 has long
been an earnest advocate of the injections as the only method by which a
real intensive treatment is possible. Civatte and Fraisse5 tried injec-
tions of the iodohydrargyrum cacodylate in sixty cases, and claim to
have had good results. Jullien6 is a most active and enthusiastic friend
of the treatment. He claims that early abortion of the disease is pos-
sible by means of calomel injections. He has no abscesses, which are
caused by traumatisms, the use of iodide of potassium, which combines
with the mercury to form the irritating biniodide and ordinary pus in-
fections. He calls especial attention to the necessity of adjusting the
amount of the mercury injected to the patient's weight, as well as in
accordance with the other indications. This is a point that I have re-
peatedly insisted on. It is absurd, even if other things are equal, to
administer the same amount of the drug in a patient weighing two hun-
dred pounds as in one weighing one hundred pounds. Desesquelle7
prefers to use the bichloride, as the most antibacterial of all the prepa-
rations. Pezzoli and Porges* prefer the salicylate of mercury; they
have given thousands of injections without a single abscess.

This list might be multiplied many times if I attempted to note all
the articles that have appeared during the year on the hypodermic
treatment of luetic disease. Enough have been given, however, to show
the rapid increase in favor with which this mode of administration is
regarded by syphilographers. It will not be out of place to consider
the recently recorded ill-effects.

Neumann and Bendig9 record a case of diffuse gangrene after intra-

1 American Medicine, October 31, 1903.

2 Presse Medicate ; Journal of the American Medical Association, November 28, 1903.

3 Annales de Dermatologie et de Syphiligraphie; Journal of the American Medical
Association, March 14, 1903.

4 Journal des Praticiens, 1903, Nos. 5 and 6.

5 Annales de Dermatologie et de Syphiligraphie, 1902, p. 838.

6 Policlinique ; Monatshefte f. praktische Dermatologie, March 1, 1903.

7 Annales de Therapeutique Dermatologique et Syphilitique, 1903, No. 16.

8 Journal of Cutaneous Diseases, August, 1903.

9 Ibid., April, 1903.

SYPHILIS. 147

muscular sozoiodolate of mercury injections. There was intense pain at
the moment of injection, followed not by an abscess, but by sloughing.
A large nerve trunk was probably injured. Klotz1 had a similar expe-
rience on a small scale with the salicylate. It is possible that some
error in technique may have occasioned these accidents; at all events,
the nerve injury in the first one shows the selection of an unusual site
or the employment of an exceptionally long needle. Neubeck2 had a
death following an injection; the dose was an exceptionally large one,
and the patient was a sickly and much debilitated woman. Wormser3
has had gangrene occur, but his injections were subcutaneous, and not
intramuscular. Balzer4 has had an acute mercurial enterocolitis after
the intravenous injection of the cyanide of mercury. In the discus-
sion in the Paris Dermatological Society on this case Danlos and Bar-
thelemy agreed with Balzer as to the exceptional rarity of this or any
other accident during this treatment.

There have been but few therapeutic changes suggested. Reference
has incidentally been made above to intravenous mercurial injections.
I do not think it necessary to dwell further upon them here. They
possess no advantages over the intramuscular ones 3 the technique is
complicated and troublesome for general use, and they may at present
be regarded as outside the domain of practical luetic therapeutics.
Scholem5 uses a new preparation, colloid mercury, for his inunctions.
It is a black, metallic powder, soluble in ether and alcohol. His for-
mula is: colloid mercury, 10; distilled water, 10; lard, 80; chalk,
20 ; sulphuric ether, 1.5, and benzoic ether, 3.5 parts. Strauss6 has
tried epidural mercurial injections in ten syphilitics, but has abandoned
the method as possessing no advantages over simpler ones.

The technique of the injection was described in last year's review.7
Fuller details will be found in an exhaustive article on the subject that
will shortly appear.8 A few words may be said here as to the regula-
tion of the injection courses. There are no hard-and-fast rules, but a
general scheme would be as follows : As soon as the advent of the first
secondary symptoms renders the diagnosis positive from ten to fifteen
injections should be administered at intervals of about two weeks. If

1 Journal of Cutaneous Diseases, April, 1903.

5 Archiv f. Dermatologie u. Syphilis, July, 1903.

3 Deutsche medicinische Wochenschrift ; Monatshefte f. praktische Dermatologie,
March 15, 1903.

* Annales de Dermatologie et de Syphiligraphie, March, 1903.
s British Journal of Dermatology, September, 1903.

6 Miinchener medicinische Wochenschrift ; Journal of the American Medical Associ-
ation, August 22, 1903.

7 Progressive Medicine, September, 1903, p. 177.

* International Clinics, 1904,

1 48 DERMA TOLOG Y AND SYPHILIS.

the symptoms have then disappeared treatment is suspended for from
four to six weeks. This is followed by a second similar course and a
second interval of non-treatment. This takes about the first twelve
months. During- the second year of the disease two or three courses
with similar intervals between them are administered, and one or more
is given in the third year.

This routine is varied, of course, in accordance with the necessities
of the individual case. Severe or persistent symptoms necessitate in-
crease of the amount injected, lessening of the interval time between the
individual administration, or increase of the length of the courses, or all
of them. The minimum, however, in the most favorable cases is five
courses during three years.

DISEASES OF THE NERVOUS SYSTEM.

By WILLIAM G. SPILLER, M.D.

DISEASES OF THE BRAIN.

Brain Tumor. It may be very difficult to determine from the
clinical manifestations whether a tumor is near the surface of the
brain or not, as in a case reported by Bayerthal.1 The tumor impli-
cated the left optic thalamus. Headache and optic neuritis were not
present, except that toward the terminal stage of the disease slight
choked disk was observed. The left parietal bone was tender on per-
cussion near the median line of the skull, and this sign seemed to indi-
cate that the tumor was not very deep. Bayerthal refers to the
observations of Oppenheim and Bruns, by which it has been shown
that this localized tenderness of the scalp to percussion may be present
when the tumor is situated in the white matter of the brain, but these
authors do not state how far below the cerebral cortex a tumor may
be and yet cause tenderness. Bayerthal believes that Jacksonian epi-
lepsy, monoplegia, and tenderness on percussion may be caused by a
tumor of the optic thalamus. The great inco-ordi nation of movement
in his case was regarded by him as a sign of lesion of the corpus cal-
losum.

The case of tumor of the brain recorded by Dercum and Keen2 is
remarkable, because of the large size of the tumor and because of the
difficulty of diagnosing the location. The tumor, including a hard-
ened and an unhardened portion, weighed 264 grams. The early
symptoms were very indefinite, and some of them, paralysis of the
abducens and hypsesthesia in the trifacial distribution seemed to point
to a lesion at the base of the brain. The case shows the importance of
paying attention to what may seem almost trivial symptoms. At one
time the patient had faint but unmistakable impairment of the stereog-
nostic perception in the sole of the right foot, and somewhat later
in the right hand. He had faint and somewhat inconstant symp-
toms of inco-ordination of the right fingers and right toes. During a
few days he had tenderness and pain in the post-parietal region. It

1 Neurologisches Centralblatt, 1903, Nos. 12 and 13.

2 Journal of Nervous and Mental Disease, December, 1903.

150 DISEASES OF THE NERVOUS SYSTEM.

was almost impossible to make an early diagnosis of tumor of the parietal
lobe in this ease, but later the diagnosis became easy. The removal,
surgically, of a large part of the tumor was followed by so much im-
provement in the patient's condition that both he and his relatives were
desirous of having another attempt made to remove the entire' mass.
This attempt was made three weeks later. The hemorrhage during
the operation was very abundant, and the patient died .soon after leav-
ing the operating-table. The operation was performed by Keen, and
.very means known to surgery to make the operation successful was
employed, but the tumor was so large that its complete removal caused
the death of the patient.

In a report of five eases of tumor of the brain that I have recently
published some interesting clinical observations were made. In one
case typical Jacksonian epilepsy was caused by a tumor the outer border
of which was 1.5 em. below the cortex. Jacksonian epilepsy is usually
indicative of a cortical lesion. In another case loss of stereognostic
perception and of the sense of position in the left hand, awkward move-
ments of the left fingers, and the impairment of sensation for touch,
but not for pain, in the left upper limb were signs of tumor-formation
in the right parietal lobe. The loss of the sense of position was so
marked in this case that the patient was unable to find his left hand
with his right hand when his eyes were closed, and he frequently took
hold of my hand, believing it was his own.

Tuberculous meningitis in plaques was found over the right parietal
lobe. This is a rare form of tuberculosis. The plaques are of dif-
ferent size and thickness and consist of agglomerated granulations and
fibrinous deposits. They are usually confined to a small portion of
the brain. The symptoms are like those of brain tumor.

In one of my cases,1 in which a tumor of the cerebellum was found,
repeated yawning had been observed. This sign, I think, is indicative
of a lesion at the base of the brain ; and it is found also in some cases of
acromegaly. The yawning and drowsiness may be so intense that the
patient may drop asleep while eating.

In a case of gliosarcoma of the parietal region observed by Stanley
Barnes2 the diagnosis was difficult. The symptoms had existed about
nine years. Impairment of stereognostic perception was uot present.
The gait and reflexes were normal. Jacksonian epilepsy had occurred
at long intervals. Optic neuritis was not seen until shortly before the
patient's death. Barnes thinks there can be no doubt that this tumor
was growing for nine years, and that headache, vomiting, and optic

1 American Journal of the Medical Sciences, February, 1904, p. 293.

2 Review of Neurology and Psychiatry, vol. i. p. 531.

DISEASES OF THE BRAIN. 151

neuritis were absent because the growth was so slow. Improvement
occurred under the administration of iodide of potassium. The diag-
nosis, as regards localization of the tumor, appears to have been exceed-
ingly difficult during the life of the patient.

Cerebellar Tumor. The two cases of cerebellar tumor reported
by William H. Hudson1 are of much interest, especially the first case,
as operation prolonged the life of the patient and removed almost all
the symptoms of tumor for several years. The case was really one of
cyst of the cerebellum, but, like so many cerebellar cysts, it may have
been associated with a tumor. A considerable amount of cerebellar
tissue was removed' at the operation in this case, but this does not
appear to have had bad results. The second case was one in which
a diagnosis of tumor of the right lobe of the cerebellum was made. A
tuberculous growth was removed from this lobe, and the patient was
apparently doing well after the operation, but died on the eleventh day,
from exhaustion due to diarrhoea. The diagnosis in each of these cases
could be made accurately, but the chief interest in the cases lies in the
favorable results of operative intervention.

Every case of cerebellar tumor successfully removed by operation is
worthy of record. In Fry's2 case a tuberculous tumor the size of a
sparrow's egg was found in the cerebellum, but its position is not very
clearly stated. About a year after the operation the patient wrote :
" The lump on the back of my head is larger, more prominent, and
reaches farther down on the neck. My hand, arm, and leg (right side)
are jerky to a considerable extent. The right ear is as deaf as ever.
The feeling is coming back on that side of my face. I can eat only on
the left side, and my teeth are wearing out. I go to my work every
day, solicit my own advertising and commercial work, do all the writing
and managing of my paper, and I am as hearty as a harvester."

A hernia of the brain occurred in this case after the operation, but
apparently did not cause much discomfort.

Cysts of the Brain. Congenital cysts of the brain are not com-
mon, and J. R. Hunt's two cases are worthy of record. Clinically, the
first case was especially interesting because a tumor of the optic thala-
mus caused paralysis of emotional innervation of the right side of the
face. Although this phenomenon as a sign of optic thalamus lesion has
been known many years, the cases with necropsy in which it has been
observed are not very numerous. In one of Hunt's3 cases the fourth
ventricle was dilated by a large cyst which was firmly attached to the

1 American Journal of the Medical Sciences, September, 1903, p. 503.

2 Journal of Nervous and Mental Disease, Marcli, 1904.

3 American Journal of the Medical Sciences, Marcli, 1904, p. 504.

152 DISEASES OF THE NERVOUS SYSTEM.

tloor of the ventricle, penetrated the pons, and terminated in the neo-
plasm of the optic thalamus. In the second case a glioma was found
in the right cms cerebri, and extended into the pons. A cyst occupied
the fourth ventricle, perforated the pons, was distinct from the aqueduct
of Sylvius, and appeared on the under surface of the right cms, ter-
minating in the tumor.

( Jongenital cysts in this part of the brain, and possibly in other parts,
are frequently associated with tumor, and in some cases the tumor prob-
ably arises in the wall of the cyst.

Optic Symptoms of Bbain Tumor. When changes in the optic
nerves occur as a result of brain tumor we expect to find choked disks
rather than optic atrophy; but when the latter does occur as a primary
condition it is indicative, probably, as Fritz Mendel1 says, of pressure
by the tumor on the intracranial or intraorbital part of the optic nerve.
He reports a case in which a carcinoma grew into the orbit and pressed
upon the optic nerve, causing progressive atrophy.

Hemianopsia is not likely to disappear after it has once developed,
but it did do so in a case reported by Tschirjew.2 A glioma of the
occipital lobe was supposed to be present, but inasmuch as uo necropsy
was obtained, the diagnosis is uncertain. It is likewise uncertain
whether the bilateral hemianopsia disappeared because of the mercury
employed in treatment.

Pick3 confirms the statements of Jolly that scotoma sointillans in the
hemianopic field of vision may be caused by some disturbance of the
visual pathways, and does not indicate a lesion of the occipital lobe.
Pick, however, goes farther, and shows that not only light sensations
but also hallucinations of sight may occur in the hemianopic fields, and
that these hallucinations do not warrant a diagnosis of a lesion in the
occipital lobe. The four cases he reports are purely clinical, but they
are evidence of the correctness of his statements.

Cerebral Abscess. A. L. Whitehead4 says that no record of a case
could be found by him, after a careful search, in which the temporal
lobe on each side had been destroyed by an abscess secondary to ear
disease, and such a condition, he thinks, is worthy of publication.

His patient had had a purulent discharge from both ears intermit-
tently for six years, but otherwise was healthy. She was seen by
Whitehead May 9, 1901. About the middle of March she had had
severe pain in the left ear which lasted a few days, and subsequently,
although not feeling very ill, she had beeen able to resume her usual

1 Berliner klin. Woehenschrift, 1S03, No. 33, p. 7C9.

2 Archiv f. Psychiatrie, vol. xxxviii , No. 2, p. 459.

3 American Journal of the Medical Sciences, January, 1904, p. 82.
♦ Lancet, February 13, 1904, p. 428.

DISEASES OF THE BRAIN. 153

work. For three weeks she had had constipation and almost constant
headache on the left side, and during the same period she frequently
complained of dizziness. For two days periods of mental dulness had
been noticed, and there had been marked drowsiness. Vomiting had
occurred only twice, once seven days and once two days before coming
under Whitehead's care. No paralysis of any of the limbs had been
noticed before May 9th, and no pain, swelling, or tenderness over the
mastoid region. The temperature had been normal or slightly sub-
normal. She soon became profoundly unconscious, her limbs were
motionless, the eyes deviated outward, the pupils were equal and
reacted slightly to light, at times small and at times large, and the outer
margins of the optic disks were blurred. At an operation an abscess
was found on the left side, presumably in the temporal lobe. The
patient left the hospital thirty-seven days after the operation, and
eighteen months later she was apparently perfectly well, but later cere-
bral symptoms developed. An operation revealed an abscess in the
right temporal lobe, and this abscess was drained. She made an excel-
lent recovery from this operation.

On both occasions the points by which the diagnosis was established
were the presence of a chronic otorrhoea, severe unilateral headache,
subnormal temperature, slow pulse, drowsiness progressing into coma,
and occasional vomiting. Whitehead thought, from the size of the
abscess, the second and third temporal convolutions on both sides must
have been practically destroyed. After the operation taste and smell
were carefully tested, but no defect could be elicited. The hearing was
somewhat diminished on the left side, and this could be explained by
the ear disease, but ordinary conversation could be followed with ease.

Hemiplegia. L. Pierce Clark1 has confirmed Hughlings Jackson's
observation that in hemiplegia the movement of the chest is greater on
the paralyzed side in ordinary or automatic respiration, although it is
not greater in volitional breathing. I have frequently observed this
phenomenon in hemiplegia.

Crossed Hemiplegia with Paralysis of Associated Ocular
Movements. A solitary tubercle of the pons is uncommon, but this
was found in a case studied by Dr. C. S. Potts and myself,2 and caused
a form of crossed hemiplegia. The symptoms were weakness of the
muscles of the left side of the face, excepting the orbicularis palpe-
brarum ; weakness of the muscles of mastication on the left side, and
fibrillary tremor of these muscles ; weakness of the left external rectus,
with the loss of power of associated movement of the eyes to the left,

1 American Journal of the Medical Sciences, December 1903, p. 1029.

2 University of Pennsylvania Medical Bulletin, December, 1903, p. 362.

15-1 DISEASES OF THE SERVOVS SYSTEM.

but with preservation of the power of convergence; diminution of the
appreciation of touch, pain, heat and cold on the right upper and lower
limbs, right side of the trunk and neck, occipital region and car; loss
of stereognostic perception and of the sense of position on the right side;
diminution of the appreciation of touch, pain, heat, and cold on the left
side of tin- fare and head ; slight loss of appreciation of heat and cold
on the right side of the face ; anaesthesia of the conjunctiva, mucous
membrane of the nose, mouth, and tongue on the left side; deafness
in the left car ; loss of taste in the left anterior half of the tongue, and
ataxia of both lower limbs, especially of the right. The tumor was
confined to the left half of the pons.

I believe this case shows that paralysis of lateral associated move-
ments, when the power of convergence is preserved, is caused by a lesion
of the posterior longitudinal bundle between the nucleus of the sixth
nerve and that of the third.

Myasthenia Gravis. An excellent study of a case of myasthenia
gravis has been made by Hun, Blumer, and Streeter.1 They were
unable to find changes in the nervous system, but did find an infiltra-
tion of the muscles and of the thymus gland with lymphoid cells, and
a proliferation of the glandular elemeuts of the thymus, the changes in
this gland suggesting lymphosarcoma. These are like the findings of
Weigert. A very .good presentation of myasthenia gravis, so far as
the disease is known at present, is given by these authors.

An unusual case of bulbar palsy without anatomical findings has been
reported by Helene F. Stelzner.2 The age of the patient, the acute
commencement, the flaccid paralysis were in favor of the diagnosis ;
but the absence of fatigue on slight exertion (this phenomenon, however,
wras not carefully tested, neither were the electric reactions), the pro-
gressive course, instead of remissions, and the integrity of the upper
branch of the facial nerve and of the upper limbs, were regarded as
uncommon in the myasthenic bulbar palsy. The muscles, apparently,
were not carefully examined. Stelzner observed implication only of
the vagus (rapidity of heart action, vomiting, and bulimia), of the
glossopharyngeus and hypoglossus (disturbance of speech and of
swallowing), and of the accessorius (tremor of the sternocleidomastoid
muscle).

Bulbar Palsy following Diphtheria. Wilfred Harris3 has observed
two cases in which there was complete paralysis of the soft palate,
almost complete paralysis of the sphincters of the eyes and lips, with
slight weakness of the frontalis, and complete escape of the muscles of

1 Albany Medical Annals, January 1904. •

* Archiv f. Psychiatrie, vol. xxxviii., No. 1, p. 171.
3 Brain, 1903, vol. xxvi., p. 543.

DISEASES OF THE SPINAL CORD. 155

expression round the mouth. In each the tongue was partially par-
alyzed, and there was considerable difficulty in swallowing. In both the
symptoms commenced with paralysis of the palate, after an illness with
ulcerated sore throat, which wras recognized as diphtheria in one
case, but there was no bacteriological evidence of diphtheria in either
case. ^Neither was believed to be a case of myasthenia gravis. Recovery
had not occurred in one instance after four years, but did in the other
after the paralysis had persisted for six years, and followed the birth
of the woman's first child.

Harris argues from these cases that occasionally permanent palsy
may result from diphtheritic paralysis, and that such palsy is usually in
muscles supplied by one or more of the bulbar nuclei. That a distinct
type of bulbar paralysis may ensue, closely resembling in its distribu-
tion that which is familiar in myasthenia gravis, but which is to be
distinguished from the latter by the non-variability of the symptoms,
the absence of the myasthenic reaction, the absence of ptosis or weak-
ness of the jaw muscles or of those of the neck or limbs. It is further
distinguished by the absence of the attacks of dyspnoea so character-
istic of myasthenia gravis, and by the presence of muscular atrophy
and the reaction of degeneration.

DISEASES OF THE SPINAL CORD.

Tabes. Accessorius Palsy. The paralysis of the larynx is not a very
rare sign of tabes, but paralysis of the trapezius or sternocleidomastoid
muscle has been reported, according to W. Seiffer,1 only six times, and
to this number Seiffer adds three cases. This author believes that the
frequency of paralysis of one group of muscles and the infrequency of
paralysis of the other indicates that these groups of muscles have different
nerve supplies, and that the nerve fibres to the larynx do not come
from the spinal accessory nerve. The paralysis in the distribution of
the accessories has varied greatly in extent and intensity in the nine
cases, and in eight of the cases the vagus also has been affected. This,
of course, is not surprising when Ave recall the relative positions of
these nerves, and the fact that in over 10 per cent, of all cases of tabes
the vagus is implicated.

Gastric Crises. Vomiting of blood during gastric crises is rare, but
was known to Charcot. Robin2 has observed a case of tabes, a man
aged thirty-seven years, who during four years had had, every two or
three months, attacks of nausea and vomiting. The attacks lasted two

1 Berliner klin. Wochenschrift, 1908, Nos. 40 and 41.
» Semaine M^dicale, August 26, 1903, p. 282.

156 DISEASES OF THE NERVOUS SYSTEM.

or three days, and the vomited matter toward the end of the attacks
appeared like coffee grounds, and contained red blood corpuscles, leuko-
cytes, and epithelial cells. The amount of hydrochloric acid was
diminished.

Kaki.y TABES. It is exceedingly important to be familiar with the
earlv forms of tabes, because it is possible that the disease in the early
stage may be arrested. 1 have seen a number of these incipient cases,
such as E. S. Reynolds1 reports. In one of his patients there were
double vision, shooting pains in the legs, and later Argyll-Robertson
pupil. The knee-jerks were normal, and there was no ataxia. In a
second case there were numbness in the distribution of the lower sacral
roots and Argyll-Robertson pupil. The knee-jerks were normal, and
there was no ataxia. In a third case there were Argyll-Robertson
pupil and pains and ataxia in the arms only, but the knee-jerks were
normal. In a fourth case there were paroxysmal attacks of diarrhoea,
then attacks of enteralgia, loss of knee-jerk, and Argyll-Robertson
pupil, but no other symptoms. The preservation of the knee-jerks
in three of these cases was remarkable. The third case seems to have
been one of cervical tabes.

Reynolds has noticed that not infrequently tabetic patients are child-
less, apart altogether from miscarriages. I believe that this observation
is correct. He thinks that antisyphilitic treatment may be of use in
the early stages of tabes, but he has never seen any benefit from it when
the disease is well established

Cytodiagnosis in Tabes. Small mononuclear leukocytes in the
cerebrospinal fluid, obtained by lumbar puncture, have been found by
French writers in cases of tabes ; but until S. Schoenborn's2 paper
appeared little attention has been given to the subject by German
writers so far as tabes is concerned, although lymphocytes have been
found by them in the cerebrospinal fluid in cases of chronic meningitis,
especially of tuberculous nature. In acute, especially purulent menin-
gitis, the cells are polynuclear and large mononuclear leukocytes. Ac-
cording to certain recent French writers a more or less intense lympho-
cytosis occurs in the cerebrospinal fluid in all syphilitic and meta-
syphilitic diseases of the central nervous system. In addition to these
there are very few nervous diseases in which lymphocytosis of the
cerebrospinal fluid occurs and only in those in which meningitis is prob-
able. Schoenborn confirms by his investigations the importance of
lymphocytosis in syphilitic and parasyphilitic affections. A few lympho-
cytes may be found in normal cerebrospinal fluid, but more than three
or four in one field under a magnification of 400 to 450 times is to be

1 Review of Neurology and Psychiatry, March, 1904, p. 177.

2 Neurologisches Centralblatt, 1903, No. 13, p. 610.

DISEASES OF THE SPINAL CORD. 157

regarded as a pathological condition. Schoenborn has found on an
average thirty to forty in one field, and some of the French writers
have found more than a hundred. The technique is important, and
may be found by those interested in the subject in Schoenborn's paper.

The value of cytodiagnosis is questioned by Czerno-Schwarz and Bron-
stein.1 Their findings of lymphocytes or polynuclear cells are in great
part like those of others, and yet they say that the practical importance
of cytodiagosis in meningitis is not great. This whole subject is at
present receiving much attention, and opinions regarding it vary.

Optic Atrophy. In confirmation of the views of Hirsch that optic
atrophy may be caused by arteriosclerosis, I refer to an interesting
case of Pechin and Rollin,2 in which the left ophthalmic artery was
much thickened and was hard, and compressed the optic nerve so that
the latter was flat like a ribbon. The abducens and the other nerves
in the wall of the cavernous sinus were also compressed by the sclerotic
bloodvessels. Optic atrophy must not be regarded as an infallible
sign of tabes.

Pupillary Phenomena. Alessandro Marina3 has pointed out some
of the errors in the explanations given for contraction of the iris in
convergence of the eyeballs. He has shown that in apes, after another
ocular muscle is transplanted with the rectus internus and convergence
becomes again possible, the iris still contracts in convergence of the
eyeballs, although the internal rectus is not functionating in this move-
ment, but does not contract in lateral movement of the eyeballs, even
though the internal rectus has been so transplanted that by its contrac-
tion it causes outward rotation of the eyeball. Furthermore, passive
movement of the eyeball inward, or contraction by electricity of the
normally situated internal rectus, causes contraction of the iris. He,
however, cannot give us a satisfactory explanation for these remarkable
phenomena, but they seem to throw some doubt on the existence of a
convergence centre.

J. Piltz4 says that there are several forms of distortion of the pupil :
temporary or varying irregularity of the border, caused by a varying
unequal contraction of certain parts of the iris ; displacement of the
pupil as a whole, and constant irregularity of the border of the pupil.
These anomalies of the pupil occur very commonly in progressive par-
alysis, tabes dorsalis, and cerebrospinal syphilis, and occasionally in other
nervous and mental diseases, but only exceptionally in health. The
temporary or varying irregularity of movement of the different parts of

1 Berliner klin. Wochenschrift, 1903, Nos. 54 and 35.

2 Revue Neurologique, 1903, p. 256.

3 Deutsche Zeitschrift f. Nervenheilkunde, vol. xxiv., Nos. 3 and 4, p. 274.

4 Neurologisches Centralblatt, 1903, Nos. 14 and 15.

158 DISEASES OF THE NERVOUS SYSTEM.

the iris occurs occasionally in katatonia. The irregularity of the
pupil may be of diagnostic importance, as it may precede the appear-
ances of the Argyll-Robertson phenomenon. It is probably caused by
irritation, paresis, or paralysis of certain portions of the iris, resulting
from changes in the long and short ciliary nerves or their nuclei.

Piltz1 says he was the first to describe the myotonic rear/inn and lie
attributes the phenomenon to a pathological process of the centre for
the iris, of the efferent fibres of the iris, or of the iris itself. Disease
of the iris, he thinks, cannot explain all cases, even though Sanger and
Willu-and have frequently been able to observe alteration of the tissue
of the iris in cases of tabes and paretic dementia by means of the cor-
neal microscope. If the cause were always to be found in the iris the
slowness and the persistency of contraction should be found in all cases
in accommodation, convergence, and reaction to light, according to
Piltz, and this is not the case. Often, Piltz believes, the cause must be
sought in disease of the central nervous system, and therefore, he thinks,
the names of neurotonic light reaction, neurotonic convergence reaction,
and neurotonic orbicularis reaction are most suitable for these cases.
The name of myotonic pupillary reaction he would retain for those cases
in which some pathological alteration of the iris can be determined and
the myotonic reaction is present in all the pupillary reflexes that still
persist. For all forms in which this myotonic phenomenon is present
he suggests tonic reaction of the pupil or tonic pupillary movement.

While most writers seem to agree that myotonic pupillary reaction is
not the best name for the phenomenon, it is unfortunate that almost
all find it necessary to suggest new names, so that it is becoming
difficult by the title of a paper on this subject to understand what is
meant. This is well illustrated by the two papers by Rothmann
and by Piltz in the same number of the Neurologisches Centralblatt,
with entirely different titles.

Max Rothmann2 has observed the myotonic pupillary reaction — i. c,
failure of reaction to light, with slow contraction in accommodation
and convergence and slow dilatation after cessation of convergence and
accommodation — in a child of twelve years. After convergence or
accommodation had ceased thirty or forty-five seconds elapsed before
the pupil dilated. The right pupil was dilated ad maximum. The
child in other respects was healthy, and neither she nor her parents had
had syphilis, but she suffered from migraine. Rothmann refers to com-
plete or partial oculomotor palsy occurring in attacks of migraine, even
ophthalmoplegia interna, and seems inclined to accept the explanation
that these palsies are caused by hemorrhage into the nucleus of the

1 Neurologisches Centralblatt, 1903, p. 253. 2 Ibid., p. 242.

DISEASES OF THE SPINAL CORD. 159

oculomotorius. A small hemorrhage into the nucleus of the branch
supplying the right iris seems to him to afford a plausible explanation
for his case. The accommodation nucleus must have escaped. After
a time the pupil became smaller than it had been immediately after the
paralysis. The myotonic pupil was not observed until one year after
the paralysis of the sphincter iridis had occurred, and Rothmann
believed that slight contracture of the iris had occurred. He com-
pares the phenomenon with the condition occurring in palsy of the
face. In facial palsy of long duration, with partial restoration of motion
and with secondary contracture and moderate deepening of the nasolabial
fold, occasionally one may observe that after stronger contraction of the
paretic muscles, as in laughing, the nasolabial fold remains deeper for
a time, and gradually lessens as the muscles return to the condition
of moderate contracture. Rothmann dislikes the name of myotonic
pupillary reaction, and properly, because it would lead to confusion in
suggesting some relation to Thomsen's disease when no such relation
exists.

Paradoxical Reaction of the Pupil in Accommodation. The
paradoxical reaction of the pupil to light is well known, although it is
rarely seen. The paradoxical reaction in accommodation until the report
of my1 three cases seems to have been observed only by Vysin. In this
peculiar form of reaction the pupil becomes smaller in fixing a far object
and larger in fixing a near object. It is not always associated with the
paradoxical reaction to light, viz., dilatation of the pupil in light and
contraction in darkness, and, indeed, it was not so associated in my
three cases. The significance of the paradoxical reaction in accommo-
dation is as yet undetermined, but it seems doubtful whether it will
have much clinical value. As it has been observed only in the cases
of Vysin and my own, it is wise to wait until further cases are reported
before we come to any conclusion regarding the importance of the sign.
Vysin's two cases were functional, but one of mine was certainly
organic. It was impossible to make a positive diagnosis. The pupils
were equal and the iridis reacted promptly to light. The pupil
dilated when the eyeball was directed downward and inward, but con-
tracted in looking at a far object, The same phenomenon was observed
in accommodation, the contraction occurring in looking at a far object
and the dilatation is looking at a near object. One of the cases was
probably hysterical, and in another no signs of disease were detected.
In two cases there was weakness of one internal rectus. The tests
were carefully made in all three cases, and the contraction of the pupil
in fixing a far object was not caused by upward movement of the

eyeball.

1 Philadelphia Medical Journal, 1903, p. 756.

1(50 DISEASES OF THE NERVOUS SYSTEM.

Spinal Tumor. A very important case of tumor of the upper cer-
vical vertebra is reported by J. J. Putnam and J. W. Elliott.1 The
first, second and third cervical vertebra? were exposed, and their laminae
removed. The posterior surface of the axis was found to be eroded,
so that on grasping it with forceps it came away as a thin shell of dis-
integrated bone, disclosing a small grayish lobulated tumor, the size of
an acorn. It was found to be a giant-cell sarcoma. It seemed to
involve the dura and perhaps the cord. The base was curetted, as
well as the body of the secoud cervical vertebra, and a quantity of dis-
eased tissue was removed from the vertebra in front of the cord. The
man was still living about four and a half years after the operation.
He had signs of implication of the spinal cord; but he had been gaining
steadily, and showed no indication of recurrence of the tumor.

This is the first instance in which an operation has been done for
a tumor situated so high in the vertebral column, the case that comes
nearest to it being that described by J. W. Putnam, Krauss and Park,
in which a sarcoma was successfully removed from the neighborhood
of the fourth and fifth cervical segments.

The case of Putnam and Elliott shows remarkable improvement when
it is considered that all the sarcomatous tissue probably was not removed.

Two other cases of tumor of the vertebral column, with operation but
not very brilliant results, although pain was lessened in one of the
cases, are reported by these authors.

Spinal Cyst. The following case, reported by Spiller, Musser, and
Martin,2 is an example of a rare condition, viz., intradural spinal cyst.
The patient was a woman aged twenty-six years. In April, 1901, she
began to have sharp pain down the front of the left thigh as far as the
knee, and felt only at night. By October, 1901, the pain extended
across the lower part of her back. She had, also, pain over the left
sacrosciatic foramen. She came to Philadelphia on January 2, 1902,
and for two weeks after her arrival she had obstinate constipation.
On February 8, 1902, the pain was felt over each sacrosciatic foramen,
in the sacral region on both sides of the vertebral column, and down
the anterior part of the left thigh. The patellar reflex on each side
was exaggerated, and patellar clonus was present on each side. Babin-
ski's reflex seemed to be present on the left side. Ankle clonus was
not obtained. There was no objective disturbance of sensation. The
upper limbs were not affected. Three days later patellar clonus and
the Babinski reflex were not obtained. There was no girdle sensation.
On June 10, 1902, the pain had become more severe and was still felt

1 Journal of Nervous and Mental Disease, November, 1903.
3 University of Pennsylvania Medical Bulletin, 1903.

DISEASES OF THE SPINAL CORD. 161

chiefly down the front of the left thigh, and occasionally down the
back of this thigh. There was no atrophy and no weakness, and no
objective 'disturbance of sensation. She had until this time had no
pain in the right lower limb. Constipation had been obstinate since
January. The patellar reflex was still exaggerated on each side. She
had noticed that once or twice pressure over the vertebral column in
the lumbar region caused a shooting pain in the back of the left thigh.
By June 26th the pain was felt also in the anterior part of the right
thigh, and the agony was so great the patient was unable to sit still.
Tactile sensation was not quite so acute in the left leg below the knee
as in the right, and she complained of much numbness in the left foot.
The patellar reflex was not obtained on the left side, but was prompt
on the right side. She was not weak at all, but two days later the
flexors of the left thigh were found to be weak, and the left lower limb
gave way when she stood. On June 30th the flexor muscles of the
right thigh also were weak, and the patellar reflex was absent on each
side.

The symptoms in this case indicated irritation of posterior roots,
with increasing compression of the spinal cord, and as the symptoms
pointed to implication chiefly of the left third and fourth lumbar
roots, it was decided to remove the lamime of the first, second, and
third lumbar vertebra, as in this way the whole of the third and the
greater part of the second and fourth lumbar roots would be exposed.
The operation was done by Dr. Edward Martin. On splitting the dura
a cyst about au inch in length and half an inch wide presented itself
in the opening. The walls of this cyst were very thin. The fluid
evacuated was clear, and after the cyst was emptied about five or six
ounces of cerebrospinal fluid gushed out with much force, indicating
unusual intradural pressure caused by the cyst, As this fluid escaped
clonic spasms were noticed for a few moments.

The patient made a good recovery from the operation, and gradually
the symptoms of spinal tumor disappeared. At the time the paper
was published she had pain at times down the front of the left thigh,
but only after walking or getting excited. Full power had returned
in the lower limbs.

We were prevented from obtaining the fluid contents of the cyst on
account of the unexpected rupture of its walls. It seemed hardly prob-
able that the cyst was of parasitic nature.

Tumor of Vertebrae. Metastasis of carcinoma to the spinal verte-
bra; occurs occasionally, but the two cases reported by Ballet and
Laignel-Lavastine1 are remarkable in that myelitis was found in

1 Revue Neurologique, December 15, 1903, No. 23, p. 1129.
11

16'2 DISEASES OF THE NERVOUS SYSTEM.

both, ami in one cancer of the cord developed. The myelitis was

thought to be caused by secondary infection.

Amyotrophic Lateral Sclerosis. It seems very questionable to me
whether the ease reported by Hans Ilaenel1 is properly classified as one
of amyotrophic lateral sclerosis. According to his description, it was
clinically one of this disease, but the bloodvessels were much affected.
The large and middle-sized vessels of the meninges showed arterio-
sclerosis, but alteration of the walls was not found in the vessels of
the nervous tissue* proper, although round-cell infiltration was present
about these structures. Alteration of the nerve cells of the nuclei of
some of the cranial nerves, and of some of the nerve cells of the anterior
horns, with degeneration of the pyramidal tracts from the cerebral
peduncles into the sacral region of the cord, such as occurred in this
case, are like the lesions of amyotrophic lateral sclerosis. The degen-
eration implicated the posterior longitudinal bundle, the anterolateral
columns, the direct cerebellar tracts and Gowers' tracts, or in brief, all
the spinal cord except the posterior columns. To accept such a case
as this as one of amyotrophic lateral sclerosis is to widen greatly our
conception of the disease. Where round-cell infiltration about the ves-
sels of the spinal cord is intense we may expect alteration of nerve fibres,
and the secondary degeneration resulting from this will simulate sys-
temic disease, as in the spinal changes of anaemia. I have seen cases
like this one described by Haenel, but it has not occurred to me to class
them under the title of amyotrophic lateral sclerosis. The causes in
such cases are probably the toxic condition of the blood and diseased
vascular walls, but cases of amyotrophic lateral sclerosis occur in
which these causes do not appear.

Unilateral Lateral Sclerosis. A case reported by Mills and
myself2 seems to prove the existence of a unilateral form of lateral
sclerosis. Hemiplegia gradually developed on the right side, the lower
extremity being more markedly and probably earlier affected than the
upper, the case, therefore, at first belonging to the clinical type of uni-
lateral progressive ascending paralysis. After several years the left
lower extremity also became paralyzed, but not to the same extent as the
right. The reflexes were all markedly exaggerated, the Babinski
response being present. Sensory symptoms were absent. Microscopic
examination showed intense and long-standing degeneration of the right
crossed and the left direct pyramidal tracts, the degeneration extending
into the pons, but not into the left cerebral peduncle; also compara-
tively recent degeneration of the left crossed and the right direct pyram-
idal tracts, traced by the method of Marchi into the lower part of the

1 Archiv f. Psychiatrie, No. 1, vol. xxxvii. p. 45.

2 Journal of Nervous and Mental Disease, July, 1903.

DISEASES OF THE SPINAL COED. 163

right internal capsule. No lesions, degeneration or focal, were found
elsewhere in the brain or spinal cord ; the case, therefore, was one of
primary degeneration of the motor tracts, much greater and older in the
right crossed and left direct pyramidal tracts.

We have concluded that there is a form of progressively developing
hemiplegia, usually of ascending type, sometimes becoming triplegia,
or even quadriplegia, due to a progressive primary degeneration of the
pyramidal tracts, which begins on one side and may extend to the other.
This clinical picture may be produced by other lesions.

Poliomyelitis. I have had recently the opportunity of studying the
spinal cords from two persons who had become paralyzed in the lower
limbs during an attack of smallpox.1 I was unable to fiud sufficient
cause to explain the symptoms in the material sent me from one case, but
in the other the condition was that of anterior poliomyelitis. The
changes in the spinal cord were almost confined to the gray matter. In
a part of the thoracic region the white matter was also affected, but in
the lumbar region the implication of the anterior horns was so intense
that in a section stained by the Weigert hematoxylin method to the
naked eye these horns stood out from the surrounding tissue as light
areas. The anterior spinal system of vessels evidently had conveyed
the poison. The case was a satisfactory example of poliomyelitis in an
adult, and of smallpox as one of the causes of this disease.

Muscular Atrophy. An extraordinary case of muscular atrophy
occurring in a girl aged eleven years is the following, reported by
Fletcher and Batten •? For twelve months there had been weakness of
the hands, for seven months she had been unable to button her clothes,
for four months she had had weakness of the legs, for fourteen days she
had had pain in the back and increased difficulty in swallowing. She
was intelligent, deaf, had some atrophy of the tongue, weakness of the
neck, and thoracic respiration, the upper intercostals alone being in use.
She had claw-hand, wrist-drop, and weakness of the upper arm and
shoulder muscles. She walked feebly, the knee-jerks were brisk, and
sensation was normal. Reaction of degeneration was present in some
of the muscles. Sudden death occurred from respiratory failure.

Extensive destruction and atrophy of the cells of the anterior horns
from the upper cervical to the lower thoracic segments was found; the
cells of Clarke's column also were affected. The ventral region of the
cord in the thoracic segments was degenerated. The direct cerebellar
tracts also were degenerated.

This seems to have been an unusual case, and it is at present difficult
to determine where it should be classified.

1 Brain, Autumn, 1903, vol. xxvi. p. 424. * Ibid., p. 473.

164 DISEASES OF THE NERVOUS SYSTEM.

Syringomyelia. Hemorrhage into a Cavity in the Cord. Gowers1
believes that cases of sudden or rapid disease of the spinal cord are some-
times the result of hemorrhage into a congenital cavity in the eord.
Syringal hemorrhage is not a hypothesis, because Gowers has described
a spinal cord in which a cavity, evidently congenital from its limitation
by embryonal tissue, was rilled with blood from the cervical region to
the lower part of the cord. It passed from the central canal backward
on the inner side of the posterior horn. Through part of the thoracic
region a similar smaller cavity existed adjacent to the right posterior
horn, in which there was no blood. The cervical region was torn and
distended with blood, and it seemed as though the hemorrhage had begun
here. Gowers thinks that syringal hemorrhage is seldom fatal ; pos-
sibly this is the reason the condition is so little known, and our recog-
nition of the condition rests almost entirely on clinical cases, such, for
example, as one recorded by Gowers. A man awoke one morning and
found that during the night motor and sensory palsy of his left arm had
developed. Two months later he had complete paralysis of this arm
and also of the sternocleidomastoid, trapezius, and pectoralis, with slight
wasting, and only slight diminution of electrical excitability of the
muscles to faradism and galvanism. Sensibility was lost in all forms,
over the arm and neck up to the edge of the jaw, and over the side of
the thorax down to the edge of the ribs. The patellar reflex on the
same side was exaggerated. Four years after the onset there was only
slight weakness of some movements of the arm and slight diminution
of sensibility in the upper arm, shoulder, and over the scapula. There
were one or two other symptoms suggestive of syringomyelia, and there-
fore the case was regarded as one of syringal hemorrhage.

I have no intention of questioning this diagnosis, especially as it was
made by so capable an observer, but I may mention that I2 have had a
case recently, and reported it with Weisenburg, in which paralysis of
one upper limb was caused by disease of the bloodvessels and perivas-
cular sclerosis confined to one lateral column and anterior horn. It is
a question whether a pre-existing cavity is necessary for the development
of such symptoms, as in the case reported by Gowers. There is no
doubt that a cavity in the cord would be more likely to confine the
blood poured out to a definite area, but the possibility remains that the
hemorrhage may be on one side of the spinal cord without the existence
of a cavity.

The Root Type of Sensory Disturbances in Syringomyelia.
A case observed by J. Dejerine3 seems to show that disturbance of sen-

1 Review of Neurology and Psychiatry, No. 3, vol. i. p. 155.

2 University of Pennsylvania Medical Bulletin, 1903, p. 133.

3 Journal de Physiol ogie et de Pathologie G£ne"rale, July, 1903.

DISEASES OF THE SPINAL CORD. 165

sation caused by a lesion confined to the posterior horn is radicular in
type — i. e., when a limb is affected by the lesion the alteration of sen-
sation is in a longitudinal band on the limb. His patient was a man
who had become paralyzed in the lower limbs after a fall. Tactile
sensation was normal in the trunk above the umbilicus and in the upper
limbs, but analgesia and thermoanesthesia were present on the right
side of the thorax, both back and front, as high as 2 or 3 cm. below the
clavicle and on the inner side of the right upper limb. The dissocia-
tion of sensation was like that occurring in syringomyelia, and was in
the distribution of the seventh cervical to the eighth thoracic roots in-
clusive. A cavity was found in the right posterior horn, extending as
high as the seventh cervical segment. Dejerine thinks that a lesion of
the posterior horn in any segment will cause disturbance of sensation
in the same parts as when the posterior roots of this segment are injured.
This case he has reported in abstract previously.

Hypertrophy in Syringomyelia. Syringomyelia with hyper-
trophy of certain parts of the limbs, known as cheiromegaly (Hoffmann,
Marie) or as mairosomia (Schlesinger), occurs under the form of Mor-
van's disease. The enlargement of the parts often is caused by an
increase in the bony as well as in the soft tissues, but more commonly
in one or the other alone. In a case reported by Alfred Schlittenhelm1
the phalanges in both hands were atrophic, but the soft parts were hyper-
trophic. This is an unusual finding.

Brown-Sequard Paralysis. Bilateral Brown-Sequard paralysis was
observed by Brissaud in a case without necropsy, and now F. Jolly2 has
reported a similar case, in which a microscopic study of the spinal cord
was made. The paralysis occurred in two attacks. The right lower
limb became paralyzed and the left paretic, and anaesthesia, especially
analgesia, was observed in the left lower limb. Paresthesia was present
in both buttocks. After two months -much improvement occurred, the
weakness of the right lower limb was less, and sensation of the left lower
limb was nearly normal. An acute attack then occurred, and the patient
became paralyzed in the left lower limb and analgesic and thermoanses-
thesic in the right lower limb, with diminished tactile sensation in this
limb. Jolly had supposed that the case was one of syphilitic myelo-
meningitis, but no signs of syphilis were found by microscopic examina-
tion. The condition was one of myelitis of the upper thoracic cord.
The patient had complained of pain, but, inasmuch as no meningitis
was present, the pain was believed by Jolly to be caused by the lesion
of the central pain tracts, and not by disease of the spinal roots. The
case seems, therefore, to show the possibility of pain being caused by

1 Neurologisches Centralblatt, November 1, 1903, No. 21, p. 1006.

2 Arch. f. Psych., No. 2, vol. xxxvii. p. 598.

\(]Q DISEASES OF THE NERVOUS SYSTEM.

a lesion confined to the spinal cord without implication of the spinal
membranes.

Landry's Paralysis. Gordinier1 has made a careful study of
Landry's paralysis, and reports two cases. In his first case there was
rapidly ascending motor paralysis, terminating fatally, with bulbar
symptoms, nine days after the onset. Sensory symptoms were absent
preceding or during the course of the disease. A history of intestinal
autointoxication two weeks prior to the onset of the paralysis was obtained.
The anatomical findings indicated a primary degeneration of the periph-
eral motor neurones. The second case was remarkable because of re-
covery.

Multiple Sclerosis. An unusual and interesting case of multiple
sclerosis has been studied by J. R. Hunt.2 There seems to have been
in this case a combination of multiple sclerosis with paretic dementia.
Hunt has found only seven cases similar to his reported, and of these
six were with necropsy. The diagnosis of the combined form has never
been made from the symptoms, and it is somewhat doubtful whether it
could be. There are many points of resemblance between the two diseases.

Spastic Paraplegia. It is certainly worthy of record that a case of
spastic paraplegia should result in recovery with disappearance of the
paralysis, and therefore I give space to brief mention of such a case
reported by Nicod-Laplanche.3 The paraplegia developed after child-
birth. The writer believes he can exclude hysteria and syphilis.

Myelitis. The association of optic neuritis with myelitis has been
observed by different neurologists. In the recent case reported by Bris-
saud and Brecy4 the patient, a male aged sixteen years, had severe head-
ache one evening, the next day vision was disturbed, the following day
he had weakness in his lower limbs, and died thirteen days later,
having presented the clinical picture of ascending paralysis. Myelo-
encephalitis was found. These authors believe that in most similar
cases the optic neuritis is caused by infection.

Paralysis of Abdominal Muscles. Oppenheim5 has made an impor-
tant study on the paralysis of the abdominal muscles. He has observed
three cases in which this paralysis was the result of neuritis. The ab-
dominal muscles may be paralyzed with other muscles, or the neuritis
may.be confined to the nerves of the abdominal wall. The neuritis
of the intercostal nerves may be in association with herpes, or may
be caused by malaria, typhoid fever, alcoholism, gout, diabetes, etc.

1 Albany Medical Annals, January, 1904.

2 American Journal of the Medical Sciences, December, 1903.

3 Semaine Medicale, March 9, 1904, No. 10.

* Revue Neurologique, January 30, 1904, p. 49.

* Deutsche Zeitschrift f. Nervenheilkunde, Nos. 5 and 6, vol. xxiv. p. 325.

DISEASES OF THE SPINAL CORD. 167

When the neuritis is unilateral the symptoms are unilateral, and there
are pain in the course of the lower intercostal nerves, tenderness on
pressure over the affected nerves, paresthesia, paralysis of the abdomi-
nal muscles, loss of the abdominal reflexes, hyperesthesia or anesthesia,
deviation of the umbilicus toward the sound side, and protrusion of
the abdomen on the paralyzed side, especially in coughing, bearing
down, and crying. The electrical reactions are also altered.

The abdominal muscles are more often affected by spinal cord lesions
than by lesions of the peripheral nerves. In the former type gradually
developing paralysis, with alteration of the electrical irritability, at first
unilateral and without much paralysis of the lower limbs, indicates a
process in the cord segments or motor roots innervating the abdominal
muscles. Spastic paralysis of the abdominal muscles may be caused
by a lesion higher in the cord. Slight differences in the electrical irri-
tability occur in normal persons, and a large amount of fat in the
abdominal wall interferes with the electrical test. The abdominal
muscles are innervated from the lower five or six thoracic roots, and
possibly, also, from the first lumbar. Lesions of the lower thoracic
roots cause a diffuse atrophy of the abdominal muscles, and it is impos-
sible to say that certain parts of these muscles are innervated by certain
nerve roots. The abdominal reflex may be absent in normal persons,
even in males who are healthy and not very fat. When the abdominal
reflex disappears during disease, or when it is present only on one side
of the abdomen, it has diagnostic value. Marked difference in the
reflexes of the two sides of the abdomen does not occur in normal per-
sons. Severe lesions of the cervical or upper thoracic regions may cause
the disappearance of the abdominal reflexes. It is probable, although
not certain, that a lesion of the eighth and ninth thoracic segments
causes the disappearance of the supraumbilical abdominal reflex, while
a lesion of the tenth, eleventh and twelfth thoracic segments causes the
disappearance of the infraumbilical abdominal reflex.

The abdominal reflex is often exaggerated in neurasthenia, but may
be diminished or absent. Oppenheim has found it exaggerated in early
tabes, especially from a light tapping in the region of the mons veneris.

In order to test for paralysis of the abdominal muscles it is well to
make use of forced expiration, as in coughing, screaming, as in saying
" Ho " loudly, and laughing, to try the active pressure of the abdomi-
nal muscles, and the power of raising the trunk from the horizontal to
the sitting posture without the assistance of the hands.

Injury of the Spine. Weisenburg1 reports a case, showing bilateral
peroneal palsy from injury of the spinal cord. The absence of bladder,

1 American Journal of the Medical Sciences, May, 1904.

168 DISEASES OF THE NERVOUS SYSTEM.

rectal, and sexual disturbances indicated that the conus medullaris—
i. e., the portion of the cord between the beginning of the lilum termi-
nate and the third sacral segment, and including this segment— and
that the fibres in the lateral column controlling these reflexes were little
if at all affected. The paralysis involved principally the peroneal
group of muscles on each side, while the adductors and flexors of the
thighs, especially on the right side, were paretic. The glutei were
weak. Weisenburg finds that the cells in the anterior horns of the
spinal cord controlling these muscles have been placed by various
authors between the fourth lumbar and third sacral segments, some
writers placing the centres for the adductors and flexors as high as the
third lumbar segment. The upper limit of the lesiou was indicated by
the presence, or even exaggeration, of the patellar tendon reflexes and
the preservation of the cremasteric reflex, these reflexes showing the
integrity of the fourth lumbar segment and the lumbar segments

above.

Weisenburg concludes, and I think rightly, that this case demon-
strates that the cremasteric reflex arc must have its spinal portion
above the fourth lumbar segment, and that it is not in the sacral cord,
as some writers have thought. The preservation of the rectal, vesical,
and genital reflexes seemed to indicate that the white matter of the lat-
eral columns was not seriously affected, even in the lower lumbar and
upper sacral cord, and that the lesion must be almost confined to the

gray matter.

The steppage gait in this man was so striking that when he first
came under my observation, and before I had examined him, I thought
the case was one of multiple neuritis.

Weisenburg has followed Minor, of Moscow, in speaking of the
epiconus. Minor pointed out, in 1901, that such a symptom-complex
as was present in this case always occurs in lesions involving the gray
matter of the fifth lumbar and first and second sacral segments. In
these cases the paralysis always involves the distribution of the sacral
plexus, and the peroneal group of muscles is most affected, and the par-
alysis of these muscles lasts the longest. In some of Minor's cases the
flexors and adductors of the thigh were paretic. No cases of this type,
so far as I know, have been reported in England, and none in America,
with the exception of the one described in Weisenburg's paper. It is
therefore a symptom-complex that should be better known.

In another case reported in this paper the patellar reflexes were in-
creased, although the lesion caused by a bullet wound must have been
below the reflex arc for the patellar tendon. Little has been written
on the subject of exaggeration of tendon reflexes caused by lesions below
the reflex arcs, and yet this does occur and should receive more study.

DISEASES OF THE SPINAL CORD. 169

The third case was one of the Brown-Sequard type of spinal cord
paralysis when one-half of the sacral and lower lumbar cord is damaged.
Under such circumstances sensation and motion are impaired in the
lower limb and in the external genitalia and perineum on the same side
as the lesion ; but, in addition, sensation is impaired in the external
genitalia and perineum on the opposite side. The reason for this pecu-
liar combination of symptoms is that the sensory fibres from the lower
limb have not decussated in the portion of the cord destroyed, whereas
the sensory fibres from the external genitalia and perineum of the oppo-
site side have already decussated and are implicated in the lesion.

The report of these three cases by Weisenburg is worthy of careful
reading', because the cases are uncommon and instructive.

Fracture of Vertebra. In a case at the St. Thomas Hospital,1
London, fracture of the axis caused few symptoms. The patient, a
man, fell down stairs and struck the back of his head on the wall at
the bottom of the stairs and forced his head forward, the chin being
driven into the sternum. He got up and resumed his work the next
day, and continued to work for a fortnight afterward. He was then
examined by H. A. Easton with the .r-rays, and a fracture through the
body of the axis, with displacement of the body of that bone and the
atlas forward, was found. The man complained merely of a stiff neck
and of some pain at the back of the head and shoulders. There Avas no
paralysis. The neck was held forward stiffly and appeared to be thick-
ened. The case seems to have been under the care of W. H. Battle.

Regeneration of the Spinal Cord. The subject of regeneration of
the spinal cord has been one of intense interest during many years, and
at present the opinion of the majority of investigators is adverse to the
possibility of regeneration as regards man. The following case, re-
ported by F. T. Stewart,2 is therefore one of very unusual interest. A
woman was shot through the spinal cord and immediately had the
symptoms common in a complete transverse lesion of the cord. At the
operation, three hours after the accident, the spinal cord was found to
be severed, and the distance between the segments of the cord was
three-quarters of an inch. The two ends of the cord were brought
together with much difficulty, and were sutured.

The condition of the patient in the sixteenth month after the opera-
tion, as given in this report, was most astonishing. She was able to flex
the toes, flex and extend the legs and thighs, and rotate the thighs.
While she was sitting the extended leg could be raised from the floor.
Flexion was more powerful than extension, and any movement was

1 Lancet, July 25, 1903, p. 251.

2 Philadelphia Medical Journal, June 7, 1903, p. 1016.

170 DISEASES OF THE NEBVOUS SYSTEM.

increased by reinforcement. She could slide out of bed into her chair
by her own efforts, and was able to stand with either hand on the back
of a chair, thus supporting much of the weight of the body. The
bowels moved every second day and were under perfect control, ex-
cepting in the presence of diarrhoea. About one pint of urine was
passed three times during the twenty-four hours, but there was sometimes
incontinence during sleep. The menses were regular. She had the
sensations of touch, temperature, pain, and position everywhere, but the
difference between heat and cold was not always distinguished. The
muscles were moderately rigid, and marked ankle clonus and patellar
clonus were present on each side. There were no reactions of de-
generation, and no trophic changes in the skin or nails. Although
the patient had been bruised and burned, no bed-sores had ever devel-
oped.

The suturing of the spinal cord in this case was done three hours
after the accident, and the severing of the spinal cord by the bullet
was probably attended by less alteration of the two ends of the cord
than would have occurred had the lesion been one of compression from
fractured vertebrae. The case was therefore as good a one as can be
expected in the human being for a test of suturing the cord, though a
knife wound with greater approximation of the divided ends would
afford even a better test. The case reported by Stewart is one of the
most extraordinary in surgical literature, and in view of the results
obtained by experiments on animals, and of the imperfect restoration
of function in man after severe injury to the cord, is almost incompre-
hensible. Dr. Frazier and I have found that after a posterior root in
the dog is cut and immediately sutured degeneration occurs, and the root
does not regenerate iuto the cord. How can a regeneration of the
spinal cord in Stewart's case be explained ?

DISEASES OF THE NERVES.

Facial Palsy. Revilliod has observed that hemiplegics cannot close
the eyelids on the side of the paralysis unless both eyes are closed simul-
taneously ; later, when the paralysis in the lower distribution disap-
pears, the eyelids may be closed alone on the affected side. This is
because of the innervation of the orbicularis palpebrarum of each side
from both hemispheres of the brain, but when the tract from the oppo-
site hemisphere is damaged the innervation from the hemisphere of the
same side does not permit isolated action of the orbicularis palpebrarum,
although it is sufficient for the closure of the weakened eyelids if the
closure occurs simultaneously with that of the other side.

DISEASES OF THE NERVES. 171

Rosenfeld1 has observed that the same difficulty in closing the eye-
lids of the paretic side may occur in peripheral facial palsy when
the paralysis of the lids on the affected side has disappeared. This
phenomenon seems to have little prognostic or diagnostic importance.
The explanation offered by Rosenfeld is the same as that for central
facial palsy, viz., bilateral innervation; whereas in central palsy the
tract from the opposite hemisphere is interrupted, this is not the case
in peripheral palsy. The innervation from the opposite hemisphere,
however, is supposed to be insufficient for isolated closure of the eyelids
when impairment of muscular action is present, and the additional inner-
vation through the tract from the same hemisphere is necessary to pro-
duce the separate closure of the lids on the affected side.

Bilateral Facial Palsy. Sarbo2 observed a patient with facial
diplegia whose father had had unilateral facial palsy, and whose
mother and brother had had bilateral facial palsy. In all the cases
cold seemed to have had an etiological relation. Sarbo does not believe
that facial paralysis in the cases in which exposure to cold has occurred
is caused by infection, but attributes it to some anomaly of the Fallo-
pian canal, possibly narrowness of this canal. Alteration of the circu-
lation in a narrow bony canal, with disturbance of the lymph vessels
about the facial nerve at its exit, may be the real cause of facial palsy
after exposure to cold. The anomalous condition of the facial canal,
he thinks, may be inherited.

Contraction in Facial Palsy. Common as facial palsy is, new
phenomena are frequently observed in the study of this form of paral-
ysis. Berger and Loewy have reported recently contracture of the levator
palpebral superioris in old cases of peripheral facial paralysis. The pal-
pebral fissure is enlarged, the edge of the upper lid on the paralyzed
side is higher than that on the sound side, the upper lid does not follow
the cornea when the eye is directed downward (Graefe's sign), the eye-
lids on the paralyzed side cannot be closed, but if the upper lid is pressed
downward by the finger during several minutes the patient afterward is
able to close or almost completely close the lids.

Berger and Loewy3 remark that the principal phenomena of secondary
contracture of the levator palpebral superioris are found in Graves'
disease, and they attribute Stellwag's sign (retraction of the upper lid)
and Graefe's sign, occurring in this disease, to contracture of the levator
muscle.

Anastomosis of Nerves in Facial Palsy. It seems that, in most
cases at least, the anastomosis of the facial nerve with the spinal acces-

1 Xeurologischcs Centralblatt, 1903, p. 303.

2 Deutsche Zeitschrift f. Nervenheilkunde, Nos. 5 and 6, vol. xxv. p. 398.
s Revue Neurologique, December 15, 1903, No. 23, p. 1144.

172 DISEASES OF THE NERVOUS SYSTEM.

gory results in associated movements, but not in volitional or emotional
innervation of the facial distribution. Bernhardt,1 in speaking of a case
that he had observed, said that when the upper limb was raised volun-
tarily the facial muscles on the same side contracted. He favors the
anastomosis with the hypoglossal instead of with the spinal accessory.
Brasch also prefers the hypoglossal, as atrophy of the trapezius is thereby
avoided, and by manipulation of the tongue, which is not seen, it may
be possible to innervate the faeial muscles. The hypoglossal seems to
be the nerve of choice, especially as Bernhard has noticed that after
anastomosis with this nerve there was some innervation of the face on
the paralyzed side in laughing.

Facial Palsy from Fright. It seems strange that fright could
cause facial palsy, and yet the possibility of such an occurrence is sug-
gested by a case observed by Leonard Williams.2 Facial palsy devel-
oped the day after the patient had been much alarmed by the fall of
her baby out of her arms and down the stairs. The child was not
injured. The mother could not remember any exposure to cold. The
paralysis disappeared completely in the course of a fortnight. Inasmuch
as the author acknowledges that no similar case is to be found in the
literature, it would be better, for the present at least, to be a little
cautious in accepting fright as a cause of facial palsy.

Hypoglossus Paralysis. Unilateral paralysis of the tongue as a
result of nerve lesion is not common, and as a result of inflammation of
the hypoglossus nerve it is still more rare. Alexander Panski3 reports
a case of the latter type in which paralysis seemed to be caused by a
severe pharyngitis.

Multiple Neuritis. Paralysis Like that of Lead from Other
Causes. The paralysis caused by lead is peculiar in that the upper limbs
are most affected and sensory symptoms are slight. A similar paralysis
may follow infectious diseases, as shown by Stanley Barnes ; and recently
Williamson has reported another case which seems to belong to this
type. Sensory symptoms are slight. The condition resembles that of
progressive spinal muscular atrophy, but the etiology is different, and
there is a constant tendency to improvement. It is probably a motor
neuritis. In Williamson's4 case the small muscles of the hands and
the extensors of the fingers and wrists were paralyzed, and the flexors
of the fingers and wrists were paretic. The affected muscles were
atrophied. The paralysis followed an acute illness. The lower limbs
were not affected, and the patellar reflex was present. Alcoholism

1 Berliner klin. Wochenschrift, 1903, No. 34, p. 787.

2 Keview of Neurology and Psychiatry, September, 1903, p. 579.

3 Neurologisches Centralblatt, August 1 , 1903, p. 706.
* Brain, 1903, vol. xxvi. p. 206.

DISEASES OF THE NERVES. 173

could be excluded, and there was no evidence of lead poisoning or
diphtheria. Complete recovery occurred.

Arsemical Neuritis. C. J. Aldrich1 seems to have found in trans-
verse white lines on the finger nails an important sign of acute arsenical
poisoning. He has observed these markings in several cases of his own,
and gives references to cases seen by others. He has observed three
cases of arsenical neuritis from slow poisoning in which no streaks were
present. He gives the name of leuconychia striata arsenicalis trans-
versa to this peculiar condition of the nails.

Sciatica. William Bruce2 believes that sciatica is a disease of the
hip-joint, and says that he has found tenderness on pressure of the
nerve trunk in a very few cases. In many cases moderate pressure
over some part of the capsule of the hip-joint causes pain, and in almost
every case of sciatica softening or wasting and flattening of the hip
muscles and more or less obliteration of the natal folds of the affected
side will be found. Bending the affected leg at the knee, with passive
flexion and external and internal rotation at the hip-joint may be
painful if the case is recent. Bruce calls attention to the different
nerves that give a branch each to the hip-joint, and explains in this
way the referred pain in remote parts of the lower limb.

Nerve Suturing. The suturing of uerves, even when the conditions
are not favorable, sometimes gives most satisfactory results. J. H.
Dunn3 reports a case in which the sciatic nerve was accidentally cut and
the wound became iufected. Prolonged drainage was necessary. The
result, four and one-half years after the operation, was a perfect restora-
tion of function, excepting decided paresis of the anterior tibial group
of muscles and consequent loss in extension of the foot, which did not
much interfere with the gait. Sensation was nowhere entirely lost, but
was slightly diminished on the outer aspect of the leg, and quite de-
cidedly so on the outer dorsal aspect of the foot. Trophic disturbance
was indicated only by a characteristic perforating ulcer on the heel,
about the size of a dime, very deep, reaching almost to the bone, and
very indolent. Considering the infection of the wound and the delay
of two days in suturing, which, of course, was not a very long delay,
the results in this case were excellent.

Gasserian Ganglion Operations. In a case observed by Harvey
Cushing4 herpes occurred in the distribution of the fourth and possibly
fifth sacral roots. This seems to be the first case of the kind recorded,
and it is remarkable that it was caused by removal of the Gasserian

1 American Journal of the Medical Sciences, April, 1904, p. 702.

2 Lancet, August 22, 1903, p. 511.

s Journal of the American Medical Association, 1903, p. 1358.
4 American Journal of the Medical Sciences, March, 1904, p. 375.

174 DISEASES OF THE NERVOUS SYSTEM.

ganglion. There was also a zone of hyperesthesia corresponding to the
second and third sacral areas. In another case, in which dishing
removed the right Gasserian ganglion, herpes developed on the left
side of the face, chiefly on the nose, upper lip, and cheek, and also on
the neck, overlapping the angle of the jaw. On the right side also
was a symmetrically placed patch near the angle of the jaw, entirely
outside of the post-operative area of amesthesia. There was, of course,
no eruption in the area of the right trigeminal nerve, as the right Gas-
serian ganglion hail been removed. In this case likewise hyperesthesia
was present in the distribution of sacral roots, although herpes did not
develop. Cushing attributes these peculiar symptoms to some infection.
His cases are very remarkable.

Condition of Taste Resulting from the Removal of the
Gasserian GANGLION. Harvey Cushing,1 from a study of his cases
of tic douloureux in which he has removed the Gasserian ganglion,
reaches conclusions concerning the course of the taste fibres very different
from those of Gowers and Purves Stewart. Gowers believes that all taste
fibres reach the brain through the nervus trigeminus, and these views
are shared by Stewart. Cushing's results have been uniform and com-
pletely at variance with the views expressed above, and he has had thir-
teen cases in which the Gasserian ganglion was extirpated. Disturbances
on the portion of the tongue presided over by the nervus glossopharyn-
geus, as the result of ganglion extirpation, may be dismissed with a
word. iSo interference whatever with taste-perception posterior to the
circumvallate papilla? has ever been observed, nor has he found any
alteration iu this portion of the tongue reported by others. Contrary
to Gowers' experience, that taste may at first be preserved in the tongue
after Gasserian ganglion extirpation and later disappear, Cushing has
observed an early disappearance or partial disappearance of taste percep-
tion in a large proportion of cases, with a subsequent return in large
part of the same. All of Cushing's cases have not been examined for
loss of taste months or years after the operation, but should a loss of
taste be found under such circumstances he would attribute it to an
implication of the fibres of the chorda tympani in late degenerative
processes, which may take place in the nervus lingualis.

Whenever possible, Cushing has tested taste-perception in his cases
before operation. He has found that in many cases at least there is a
temporary diminution in acuity, or even a complete disappearance of
taste over the anterior two-thirds of the tongue after operation, which
endures for a variable number of days. The extirpation in all of these
cases, with the exception of two, was total, and the ganglion with the

1 Bulletin of the Johns Hopkins Hospital, 1903, p. 71.

DISEASES OF THE NERVES. 175

intracranial stumps of all three divisions and the sensory root was
removed in its entirety and in a state of preservation, in most cases
sufficient for photographic reproduction. The complete removal is
necessary if the examination of taste-perception is to be regarded as
thoroughly reliable, and therefore we must accept the results of Cush-
ing's study as of the highest importance. Gushing finds it hard to
reconcile his results with the contradictory observations of others.
The explanation he offers is that there may be in many cases a tempo-
rary diminution in taste during the first two or three weeks after the
neurectomy, and that examination may have been made by others during
this period of temporary loss, and the condition supposed to be perma-
nent. In his investigations it is interesting to note that irritating
stimuli, like dilute hydrochloric acid and the faradic current, were still
to be tasted, localized and recognized as acid or " coppery," but the
unpleasant sensation or " sting," owing to the loss of common sensation,
was not felt.

Cushing thinks that the early and transient disappearance of taste
may be attributable in one way or another to the post-operative degen-
eration and swelling, which, owing to the removal of the ganglion, must
affect the fibres of the nervus lingualis. In this way the neurectomy
may indirectly affect the transmission of gustatory impulses from the
anterior portion of the tongue without the necessary inference that the
chorda fibres actually pass by the trigeminal route to the brain. The
mechanical pressure of the swollen lingual fibres may cause this loss of
taste, or else there may be a certain toxic effect of the products of
degeneration of lingual fibres which temporarily interferes with the
function of the chorda tympani, as the two nerves are intimately min-
gled in a part of their course. Cushing's investigations do not afford
us any information of the course of the taste fibres of the brain, they
simply seem to show that these fibres probably are not contained
within the nervus trigeminus.

In 1897 I had the opportunity to examine a case in which W. W.
Keen had removed the Gasserian ganglion intact in 1895. The case
and report of my examination were published in the American Journal
of the Medical Sciences, November, 1898. This patient had no sense of
taste for vinegar, sugar, or salt on the right side of the tongue (the
right ganglion had been removed) in the anterior portion, but all these
substances were tasted at the back part of the right side of the tongue
and on the left side of the tongue. I have recently examined another
patient in whom taste for salt and sugar was still lost in the anterior
two-thirds of the tongue on the operated side over a year after the
cutting of the sensory root of the trigeminal nerve.

176 DISEASES OF THE NERVOUS SYSTEM.

MISCELLANEOUS NERVOUS DISEASES.

Epilepsy. M. Alleu Starr1 asks whether or not epilepsy is a func-
tional disease, and answers the question himself by regarding it as an
organic disease. He bases his arguments on a study of 2000 clinical
cases which he had seen and of which he has records. As regards
Jacksonian epilepsy, Starr distinguishes several distinct types: 1. A
motor type, in which a local spasm of one or more parts upon one side
of the body only, followed by temporary weakness, is the characteristic.
2. A sensory type, in which a sudden hallucinatory perception occurs
in any one of the many senses, to be followed by a temporary suspen-
sion of the power of perception in that sense. 3. An aphasic type, in
which a sudden interference with the function of speech takes place,
either in its receptive or on its emissive side ; either in the power of
understanding or in the power to speak. 4. A psychical type, in which
dreamy states of the mind or imperative ideas dominate consciousness,
arresting the normal flow of thought, and often leading to automatic
acts, the object of which is not clear, and of which no conscious memory
remains.

Starr thinks no arguments are ueeded to support the position that
organic disease is the cause of Jacksonian epilepsy, and he tries to
show that what is true of the Jacksonian form is equally true of the
idiopathic form. When an aura occurs in ordinary epilepsy it is
always uniform in the same patient. The only difference between a
Jacksonian attack of the motor type and an idiopathic attack is the
extent of the spasm ; in one it is limited, in the other it is general.
In one it begins in one part and extends; in the other it begins in
many parts at once. In both forms a state of motor weakness follows
the attack, and there is no essential difference between the two.

The loss of consciousness occurring in ordinary epilepsy Starr attrib-
utes to the degree of severity and rapidity of extent of the cerebral
irritation and consequent shock ; if a Jacksonian attack becomes very
severe and widespread, consciousness is often lost.

Starr calls attention to the fact that often in ordinary epilepsy an
organic change in the brain is overlooked ; thus in two patients brought
to him for epilepsy only he found bilateral homonymous hemianopsia
which had been congenital, and neither patient was aware that vision
was defective. In both cases a history was obtained of hard labor,
with forceps delivery, and also difficulty in maintaining the life of the
infant for some days. In both the epilepsy had developed during the
second year. In Starr's 2000 cases of epilepsy 192 showed positive

1 Journal of Nervous and Mental Disease, March, 1904.

MISCELLANEO US NEB VO US DISEASES. 177

signs of maldevelopment of the brain. He thinks it is probable that
in epilepsy following some infectious disease a lesion develops in the
brain, such as a sclerotic plaque, and that these cases therefore are
organic. A study of the supposed causes of epilepsy indicates that in
the cases in which they can be accepted as probable causes they are so
because they have produced organic disease of the brain. Starr has
omitted in his published paper any remarks on the curability of epi-
lepsy, but in the reading of his paper he expressed himself regarding
the prognosis of recovery as very doubtful.

Changes in the Hair in Epilepsy. The influence of mental
condition upon the hair has always been an interesting subject, and the
case observed by F. E. Coulter1 is unlike most of those reported. A
child, aged seven years, suddenly became like an intoxicated person,
staggered, the eyes became fixed, and this was followed by a convul-
sion that started in the left arm and leg, and then soon extended to the
right extremities and face. She foamed at the mouth, bit her tongue,
voided urine, and the bowels moved. This attack lasted two days,
during which time she was unconscious, and fourteen hours of which
she had convulsions. Within three days of this attack the hair came
off from a spot behind the left ear, and a day or so later that on the
right side from the corresponding location fell out, so that the head was
bald at these places.

Coulter thinks that the case was one in which the nerves exercised a
sudden atrophic influence on the skin and its appendages, because all
the hair seemed to have been normal before the attack, but within
three days after the attack all hair disappeared from the areas described.
The character of the new hair was such as would be the product of
faulty nutrition, it was smaller in size, length, and diameter, and
markedly deficient in pigment.

The condition seems to have resembled the change in the color of
the hair which has been described after great fright or severe mental
anguish, or even after sharp pain in the head, but the character of the
alteration was very different. The case was one under the care of
Gowers, and has been carefully studied by Coulter ; therefore it is an
important demonstration of the trophic influence of the nerves over the
tissues of the body, and of the rapid alteration of tissue when this
trophic influence is changed in any way.

Jacksonian Epilepsy. Jacksonian epilepsy usually indicates a
focal lesion, but I have seen cases in which this sign, occurring with-
out other localizing symptoms, was not sufficient to warrant operation,
and the partial epilepsy was a manifestation of the so-called idiopathic

1 Medicine, 1903, p. 251.
12

17S DISEASES OF THE NERVOUS SYSTEM.

form <)( the disease. In two cases reported by C. K, Mills and J. Wil-
liam White' the Jacksonian epilepsy was associated with other symp-
toms, and operation was of benefit to the patients. Both cases seemed
to show that Jacksonian epilepsy in old accident cases which have or
have not been operated on is at least in part due to meningitis with
adhesions and anchoring of the brain. The dura was thickened in both
cases, and adhesions were present, both of the dura to the bone and of
the dura to the pia, as well as of the latter to the brain. Among the
objects of the operation were the release of these adhesions and the
removal of any membrane which may have been formed. In one case a
spicule of bone posterior to the motor area was removed. The patient
remained under observation about two months after the operation,
during which time he had one Jacksonian attack of moderate severity,
and this occurred very shortly after the operation. The second case
was one of gunshot-wound of the head, and a newly formed mem-
brane was found covering the pia and was removed. Sufficient time
has not elapsed in this case to determine what will be the ultimate
result of the operation.

Emphysema in Epilepsy. Emphysema of the neck and face fol-
lowing an epileptic convulsive attack has been observed by Ransohoff.2
The air was supposed to have escaped into the tissues from the respira-
tory tract, probably through a tear in the mucous membrane of the
trachea.

Respiratory Exercises in Hysteria. J. W. McConnelF has em-
ployed respiratory exercises during the past ten years in the treatment
of nervous diseases, neurasthenia, chorea, hysterical tremors, and other
forms of hysteria. The object of these exercises is not to have mus-
cular development at the expense of the heart and lungs. In all his
cases the general health of the patient has been considered, and in many
the treatment followed three or four weeks of rest. Overexertion
should be avoided, and the exercises should be employed for only three
or five minutes at first, and the time should be gradually increased.
The regaining of voluntary control is the fundamental principle of
respiratory exercises as a remedial agent. The patient standing erect
may take slow and long inspiration and expiration, or short inspiration
and long expiration, or long inspiration and short expiration, or short
inspiration and expiration. In all these exercises breathing should be
through the nose. Various other modifications in the breathing may
be employed, and in addition McConnell recommends the use of one-
half pound dumb-bells or a light-weight pulling machine. He says that

1 University of Pennsylvania Medical Bulletin, 1903, p. 2.

2 Neurologisches Centralblatt, January 16, 1904, p. 53.

3 University of Pennsylvania Medical Bulletin, 1903, p. 42.

MISCELLANEOUS NERVOUS DISEASES. 179

the strictest attention must be paid to the exercise. The movements
are of necessity slow and simple, and yet should be varied so as to
keep the patient interested. The character of the disease and the con-
dition of the patient should govern the length of time consumed in one
treatment. Three minutes of work may be followed by exhaustion,
requiring rest of an hour or more. The best plan is to commence with
simple respiratory or physical exercise, or both, for one or two minutes,
allowing the patient to rest for five minutes before proceeding, but
overdoing must be avoided.

Neurasthenia. Higier1 has found the hydrochlorate of heroin use-
ful as an anaphrodisiac. He has been able to control nightly emissions
with this drug, and has found it of service in treating the sexual excesses
of early tabes. Larger doses are needed than are given in pulmonary
affections. Three mlg., the usual dose for cough, he found useless, and
was obliged to give two or three times this amount, and the effect of
the same dose diminished after the drug had been given a while.
Hydrochlorate of heroin, he thinks, deserves a trial in sexual neuras-
thenia.

Chorea. L. Harrison Mettler3 remarks that syphilis is rarely men-
tioned as a cause of chorea, and he reports a case in which syphilis had
been inherited, and chorea first appeared when the boy was seven years
of age. The movements were general. Four attacks occurred about
a year apart, and each was more severe than the previous one. All
the usual remedies for chorea were tried, and failed. Two weeks
after beginning the administration of iodide of potassium there was a
noticeable diminution in the jactitations, and in a week or two more
they ceased entirely. The manner in which syphilis produces chorea
is unknown.

Chorea Associated with Graves' Disease. Dieulafoy has ex-
pressed the opinion that true chorea is often associated with Graves'
disease, and never precedes it. G. A. Sutherland3 reports two cases
which seem to show that the chorea may be followed by Graves' dis-
ease, and then he attempts to point out the numerous points of resem-
blance between the two affections. In both there is a neuropathic
tendency. Often there is a history of rheumatism and heart disease in
the relatives. Both affections are more common in females. Some
sudden shock is frequently the immediate cause of either affection.
Mental symptoms are common in both, and paralysis also occurs.
And yet, what is the relation between the two disorders whose path-
ology is unknown to us?

1 Neurologisches Centralblatt, March 16, 1904, p. 256.

2 American Journal of the Medical Sciences, September 1903, p. 481.
5 Brain, 1903, vol. xxvi. p. 210.

!30 DISEASES OF THE NERVOUS SYSTEM.

Graves' Disease. Paralysis occurring in the course of Graves' dis-
ease is not very common, and possibly is not well known. Charcot
seems to have been the first to describe it. The relation which this
paralysis bears to Graves' disease has not been determined. M. Rosen-
feld refers to a number of reported cases of paralysis in Graves' disease,
but savs he has been unable to find any in which the paralysis was of
the Landry type and was the beginning of the cachectic stage of Graves'
disease, as it was in a case he observed. A man aged nineteen years
had shown symptoms of Graves' disease for a year, but had had no
impairment of his physical or mental functions. He then complained
of pain in the back and weakness in the lower limbs during three days,
and on the third day became paralyzed in the right lower limb, and
showed signs of collapse. Within a few hours the left lower limb
became paralyzed, and the paralysis soon extended to the muscles of
the trunk, upper limbs, and neck, and became complete. Sensation
was normal. After twenty hours the paralysis gradually diminished
in intensity, although it did not disappear, and the attack was repeated
twice within a few days. Hysterical stigmata were not detected. At
the time the report was made the gait was very uncertain, and symp-
toms of Graves' disease were very pronounced.

Rosenfeld1 believes that hysteria could not be considered as the cause
of the paralysis on account of the manner of development of the symp-
toms, the prodromal signs, the intense collapse in the beginning of the
paralysis, the disappearance of the right patellar reflex and the weak-
ening of the left, the flaccidity of the paralyzed limbs, the pain, and
the slight tenderness of the nerve trunks on pressure, and he ascribes
the symptoms to an acute intoxication which in some way was related
to Graves' disease.

Acroparaesthesia. Pick has made the interesting observation that
in acroparesthesia the subjective disturbance of sensation occurs in the
distribution of the posterior cervical roots, and now Dejerine and Egger2
show that this observation was correct, but that in addition there is
hyperesthesia in root territories. This is not so evident in the hand,
but in the forearm and arm the hyperesthesia may be found in a band
extending along the outer or inner side of the limb, according to the
roots affected. Acroparesthesia therefore is caused by an irritative
lesion of the posterior roots in their intramedullary portion, and there
is much resemblance between these disturbances of sensation and those
of tabes.

Tetany. Tetany is such a rare disease in America that few physi-
cians here have an opportunity to study its pathology. It is, neverthe-

1 Berliner klin. Wochenschrift, June 9, 1902, p. 538.
' Revue Neurologique, January 30, 1904, p. 54.

MISGELLANEO US NER VO US DISEA SES. 181

less, interesting to know that A. Pick1 has found calcification of the
small vessels of the brain in four cases of this disease. The vessels of
the dentate nucleus of the cerebellum are affected, and to a less extent
those of the central ganglia of the cerebrum ; while those of the cere-
bral and cerebellar cortex escape. Four cases, of course, are not suffi-
cient to establish the pathology of tetany, and Pick is very guarded in
his statements, but as necropsies in cases of tetany are rare, it seems
remarkable that this selective tendency to calcification should have
been observed by Pick in four cases.

Infantilism. Two distinct types of infantilism are to be recognized :
the type of Lorain and the type of Brissaud, or myxcedeniatous
infantilism. In the first the individual is well developed, but is in
miniature ; he is short, has no hair on the face, in the axilla or genital
region, and the sexual organs are small. In the second type the face
is round, the lips are full, the nose is not prominent, the face is lacking
in expression, the skin is thin, the hair is scanty, including that of the
eyebrows and eyelashes, of the axilla and external genitals, the trunk
is long and cylindrical, the abdomen is prominent, the limbs are round,
the fat tissue is well developed, the sexual organs are rudimentary, the
voice is thin and high, the larynx is not prominent, the thyroid gland
is not felt, and the mental condition is that of a child. If the person
is a female, menstruation does not occur, the breasts do not develop,
the neck remains youthful, and the hips are not large. The infantilism,
type of Lorain, has not been shown to be dependent on imperfect de-
velopment of the thyroid gland, according to Luigi Ferrannini,2 but on
infection, intoxication, general disturbances of nutrition, as in pulmo-
nary and cardiac diseases, etc.

Intermittent Lameness. The cases of intermittent lameness observed
by H. Idelsohn3 are especially interesting, because in a considerable
number of them flatfoot was found, and Idelsohn believes that the two
conditions may have had a close relation to one another. Flatfoot,
he says, like intermittent lameness, is common among the Jews, and is
a cause of circulatory disturbance. The occurrence of flatfoot in asso-
ciation with intermittent lameness has been overlooked by most ob-
servers.

Osteosensibility. If a tuning-fork in vibration is placed upon any
part of the body where bone is near the surface a peculiar vibration
sensation is perceived, which, according to Egger, is transmitted through
the bone — i. e., through the periosteum, ligaments, and joint capsules.
This form of sensation is present in all normal persons, and is more

1 Neurologisches Centralblatt, August 16, 1903, p. 754.

* Archiv f. Psychiatrie, No. 1, vol. xxxviii. p. 206.

3 Deutsche Zeitschrift f. Nervenheilkunde, Nos. 3 and 4, vol. xxiv. p. 285.

182 DISEASES OF THE NERVOUS SYSTEM.

acute in the young than in the old, but may be altered in disease of
the nervous system. The investigation must always be carried out with
tuning-forks of the same kind, and those of high vibrations must be
avoided. Rydel and Seiffer1 have made some studies on sensation, and
they conclude that often in both peripheral and central disease there is
much conformity between the disturbance of the cutaneous and deep
sensation with that of the bony sensation. In tabes this conformity is
not so evident, although conformity exists between the degree of ataxia
and the degree of alteration of bony sensation. When cerebral disease
causes hemiplegia and hemiamesthesia the osteoanfesthesia or hyp-
sesthesia extends, like the forms of diminished sensation, to the middle
line. The study of osteosensibility promises to be of clinical value.
This subject has been studied in this country by P. C. Knapp.2

Myoclonus Multiplex. J. R. Hunt,3 in a study of paramyoclonus
multiplex, concludes that this name should be reserved for the form
of myospasm that is characterized by multiple, spontaneous, isolated
contractions of individual muscles. This type, he thinks, is peculiar
and distinctive, and receives its most logical explanation in a disturb-
ance of the spinal centres. It should be carefully separated from the
cerebral type of the myospasms which are characterized by more or
less co-ordinated movements, such as are observed in the maladie de tie,
tie convulsif, and the convulsive tremor of Pritchard and Hammond.
The contractions of paramyoclonus multiplex Hunt regards as closely
related to the myokymia and fibrillary contractions. Paramyoclonus
multiplex, he thinks, may occur as an idiopathic or a deuteropathic
affection, in the latter complicating various organic and functional
diseases of cerebral and spinal origin.

Hunt reports a case of myoclonus multiplex with necropsy, and re-
marks that Friedreich's case and his own are the only reported cases
with systematic histological examination. The examination in Hunt's
case showed that the nervous system was normal. The muscle fibres
were considerably hypertrophied, and sarcolemma nuclei were found
between the sarcous elements. The histological examination of the
spinal cord and biceps muscle in Friedreich's case was negative in its
results.

Acromegaly. Acromegaly is a rare disease, and it is not often that
one has the chance to see it in the acute form. According to Stern-
berg, in all cases with acute progress, and only in these cases, a sar-
coma of the hypophysis is found. In the case reported by W. M.

1 Berliner klin. Wochenschrift, August 17, 1903, No. 33, p. 765, and Arch. f. Psych.,
No. 2, vol. xxxvii. p. 488.

8 Journal of Nervous and Mental Disease, 1904, p. 25.
* Ibid., July, 1903.

MISCELLANEO US NER VO US DISEASES. 1 83

Stevens1 three years seem to have been required for a development of
the symptoms. At the necropsy a large tumor, a small round-cell
sarcoma, was found in the situation of the hypophysis. The symp-
toms presented were those of tumor of the pituitary body, viz., head-
ache and failure of vision, and those of acromegaly, viz., alteration of
the face and enlargement of the hands and feet. The progress of the
disease during the last three weeks of life was rapid, and the facial ap-
pearances altered much within that time. Trephining was done in
order to relieve the intracranial pressure, but it seems to have been of
no benefit.

Stevens understands by acute cases of acromegaly those lasting from
three to four years. Such cases are always fatal, because they are
caused by sarcoma of the hypophysis. He mentions that in his case
disease of the pituitary body had existed for two years before definite
symptoms of acromegaly were observed, and had his patient died one
year earlier the case would have been described as oue of disease of
the pituitary body without acromegaly. From this he argues that
cases in which disease of the pituitary body has existed without symp-
toms of acromegaly do not prove that the cause of acromegaly is to be
found elsewhere than in the pituitary body.

As regards the relation of giantism to acromegaly, Stevens says that
about 20 per cent, of acromegaliaus are giants, and also that about 14
per cent, of cases of acromegaly commence under twenty years of age.
When there is congenital absence of the thyroid gland, cretinism with
dwarfing is present. These facts suggest to Stevens that loss of
pituitary function leads to overgrowth with late union of the epiphyses,
and that loss of thyroid function has the opposite effect. He believes
that when acromegaly commences in youth it leads to giantism. Inas-
much as there are cases of acromegaly beginning in youth which show
no giant growth, he assumes that disease of the pituitary and thyroid
glands may coexist, and that it is possible that the absence of giant
growth in some cases of acromegaly in early life may be explained by
a coexisting loss of function of the thyroid gland which may inhibit
excessive growth. In any case it cannot be denied that giantism is
a frequent symptom of acromegaly.

Erythromelalgia. The pathological changes occurring in erythro-
melalgia have been determined only in a few cases, and there has been
doubt as to whether the disease is of vascular origin or nerve origin, or
both. H. Batty Shaw2 has studied the amputated portions of limbs in
three cases. He does not tell us the results of the amputation in these
three cases, and it is unfortunate that he does not, because this opera-

1 British MedicalJoumal, 1903, p. 778. 2 Ibid., p. f>f>2.

184 DISEASES OF THE NERVOUS SYSTEM.

tioii has been very serious in some cases of erythromelalgia on account
of the alteration in the vessels. In Shaw's three cases vascular changes
were present, and consisted chiefly in an increase in the intima of the
arteries, and occasionally thrombosis and changes in the inner coat of
the veins. The nerves were investigated, even to their termination,
and no degeneration was found, nor was there any suggestion of increase
of fibrous tissue in the trunk of the nerves.

This is not in accordance with the report of a case by S. Weir Mit-
chell and myself, as in that case the nerves were distinctly diseased,
nor with another case that I have studied but not yet reported. I
have shown also in another paper that pronounced vascular disease
may cause degenerative changes in the nerves, so that it is hard to
understand how the nerves escape when the bloodvessels become much
altered. One cannot say that the nerves are normal unless the most
reliable methods of investigation have been employed. Shaw says that
the affected parts in his cases after removal were hardened in alcohol
(Cases 1 and 2), and that to some extent the Marchi method was em-
ployed. It wrould be desirable to have a more detailed statement
of the methods employed, and at present I am not at all prepared
to accept his opinion that erythromelalgia, when occurring inde-
pendently of central nervous change, is associated with but one morbid
picture — that of local vascular change.

The most thorough study of a case of erythromelalgia with necropsy
yet reported is by Hamilton, and in this case both nerves and blood-
vessels were diseased.1

Achilles Jerk and Front-tap. It is important to employ the
Achilles jerk as well as the patellar reflex in our routine examinations
of patients, as one sign has about as much value as the other. Whether
it is correct or not, as Walton and Paul2 think, that the Achilles jerk
has not received the attention it should on this side of the Atlantic, I
cannot say, but in the clinics with which I am connected this reflex is
not neglected, and I am not aware that it is overlooked in other clinics.
They do not favor the Babinski method of taking this reflex over other
methods, but with this view I cannot agree. I have found it a distinct
advantage to have the patient kneel on a chair with his knees against
the back of the chair, as in this position I have gotten better relaxa-
tion of the muscles than in any other position. Their suggestion that
it is better to have the patient kneel on a cushion or a shawl rather
than on a hard wood seat is a good one. It has seemed to me that re-
inforcement, such as is commonly employed in taking the patellar reflex,

1 Journal of Nervous and Mental Disease, April, 1904, p. 217.
* Ibid., June, 1903

MISCELLANEO US NEB VO US DISEASES. 185

may be of advantage also in testing the Achilles jerk, and yet I am
under the impression that most physicians do not employ it in testing
the latter reflex. The removal of the shoes sometimes permits the ap-
pearance of a diminished Achilles reflex which could not be detected
so long as the shoes remained on the feet.

Walton and Paul have examined 500 persons of both sexes, vary-
ing in age from five to eighty-two years, either in apparently perfect
health or suffering from some trouble independent of the nervous
system, and have failed to elicit the Achilles reflex on both sides in
only one instance, and on one side in four. In these five instances the
patellar reflex was present. It would be interesting to know whether
or not in these five cases the Achilles reflex could be brought out by
reinforcement, but Walton and Paul make no reference to this. They
suggest that prior toxic influence may sometimes cause the enfeebled,
or even absent, patellar reflex occasionally found in health, and they say
that Dr. McCollom, who is at the head of the contagious service at
the Boston City Hospital, and .has seen some 10,000 cases of dipth-
theria, states that tlie patellar reflex is absent in the majority of serious
cases of this disease. Walton and Paul do not speak especially of the
value of the Achilles reflex in the differentiation of sciatic neuritis and
hysterical pain in one or both of the lower limbs. It is a sign on which
I place much reliance in making this differential diagnosis.

The front-tap has received little attention. The method of obtain-
ing it consists in smartly tapping the tibialis anticus with a hammer,
the examiner meantime flexing the foot dorsally and holding it in this
position, the ankle resting on the knee of the examiner or on the edge
of a stool. The reflex consists in plantar flexion of the foot. Walton
and Paul offer as an explanation for this phenomenon that the position
of the foot in extreme dorsal flexion puts the Achilles tendon under
such tension that the trifling tendency for the tibialis anticns to con-
tract and thus still further dorsally flex the foot is enough to stimu-
late, or tend to stimulate, the gastrocnemius into a contraction. In
500 persons, all of whom were in good health,- or had diseases having
no recognized influence on the central nervous system, Walton and
Paul found the front-tap present in 75 males, or 37.5 per cent., and
in 124 females, or 41.3 per cent. In many of these cases it was
extremely lively, so that the mere presence of the front-tap, even in
active form, does not militate against perfect health. Where a patient
has pain, as with sciatica, or osteoarthritis of the spine, they suggest
that it is well to have the foot much lower than the knee in taking
this reflex, or else to make the test with the patient in the recumbent
posture. They find that the front-tap is of less positive value in diag-
nosis than the Achilles reflex, and yet it may be of material aid in con-

186 DISEASES OF THE NERVOUS SYSTEM.

nection with other signs and symptoms. In neurasthenia, hysteria,
and other neuroses they have found the proportion of front-taps greater
than in health, namely, in 59 out of 80 eases. In 8 cases of goitre it
uas'pivsent in 7. In an epileptic attack the front-tap disappears with
the patellar reflex. In 100 cases of epilepsy the front-tap was present
in 75, absent in 120, impossible to test, on account of position of limbs
and mental condition, in 5." They were unable to find the front tap
present in any case of tabes, but it was present in 8 out of 14 cases of
paresis. In other diseases with hypertonic conditions, including hemi-
plegia, it was present, generally exaggerated, in 24 out of 28 cases.
Three of the cases in which it was wanting were old hemiplegics with
contracture and absence of other reflexes.

The conclusions which Walton and Paul draw after their careful and
important study are :

1. The Achilles jerk is practically as constant in health as the knee-
jerk. This reflex varies less in health than the knee-jerk in excursion
and activity, and is the most easily elicited and uniform of all tendon
reflexes.

2. The Achilles jerk disappears, as a rule, early in tabes dorsalis,
and its absence is as diagnostic of that disease as is loss of the knee-jerk.
They have not seen a case far enough advanced to establish tabes with
persistence of the Achilles jerk, except one case in which both the knee-
jerk and the Achilles jerk were present on one side only. They have
observed bilateral preservation of knee-jerk and loss of Achilles jerk in
2 out of 33 cases of tabes.

3. Enfeeblement of knee-jerk in health on one side or both may be
due to prior toxic influence, as diphtheria. This may also be true of
the Achilles jerk, though in the one case in which it could be demon-
strated of the knee-jerk, the Achilles jerk was normal. Further obser-
vations on this point are desirable.

4. The front-tap is present (generally on both sides) in about 40 per
cent, of individuals in ordinary health ; in some it is very active. It
follows that its presence alone, even if active, does not establish disease,
nor indicate excessive irritability of the nervous system.

5. In organic disease the front-tap is generally increased with the
other reflexes in hypertonic and decreased (generally wanting) in hypo-
tonic states.

6. In the so-called functional disorders, hysteria, neurasthenia, and
unclassified psychoses, the front-tap is present in 71 per cent, of cases.
In epilepsy it is present in 75 per cent, of cases. The test may, there-
fore, here prove of aid in combination with other findings, though its
mere presence or even activity is not of positive diagnostic value, nor
does its absence negative the existence of neuropathic conditions.

MISCELLANEO US NER VO US DISEASES. 1 87

7. Both these reflexes deserve to be placed upon the list of routine
tests for purposes of diagnosis. This is particularly true of the Achilles
reflex, which is of the greater positive diagnostic value.

Ataxia. It is believed by many that sensory disturbances cause
ataxia, and Dejerine and Egger1 point out that the alterations of the
different forms of sensation do not play the same role in the production
of this symptom, and that it is chiefly the deep sensation, the sense of
position, which influences the movements. They go farther and show
that the situation of the lesion causing a loss of the sense of position is
of much importance in determining the degree of the ataxia. In two
cases of hemianesthesia of cerebral origin implicating the tactile sense
and the sense of position, and associated with hemiparesis, the ataxia
was not excessive, not so much so as in cases of tabes. The sensory fibres
are in connection with numerous co-ordinating: centres in the cerebro-
spinal axis, and, according to Dejerine and Egger, the higher the lesion
and consequently the less destruction of the connections between these
sensory fibres and the co-ordinating centres, the less is the ataxia. If
we imagine a lesion in each of the two ends of the sensory tract — i. e.,
in the posterior roots, as in tabes, and in the thalamocortical neurones,
as in hemianaethesia from a lesion in the optic thalamus — in the first
situation the lesion would cause excessive inco-ordination, and in the
second situation it would cause much less ataxia. This idea of the
level of the lesion, and the escape of more or less co-ordinating centres,
is new and doubtless of importance in regard to ataxia, and possibly
explains why hysterical anaesthesia usually is not associated with
grave ataxia.

1 Revue Neurologique, 1903, No. 8, p. 397.

OBSTETRICS.

By RICHARD C. NORRIS, M.D.

PREGNANCY.

An Early Sign of Pregnancy. A new sign of early pregnancy is
described by H. L. E. Johnson.1 This sign is available before and
including the third calendar month, and the writer says it has been
invariably noted in a large number of cases, and only where pregnancy
has been subsequently positively demonstrated. It may be observed
as early or earlier than the fourth week, and consists of an intermittent
softening aud hardening of the vaginal portion of the cervix uteri. In
many cases a change of color from a pale violet to a normal pink hue,
or the reverse, accompanies the change in consistence. These changes
are more or less rhythmic. The change in consistence can be felt and
the change in color seen through a vaginal speculum. Johnson thinks
it is probable these changes are early manifestations of what is subse-
quently recognized as the intermittent contractions of the pregnant uterus,
and are probably caused by the change and modification in the uterine
circulation incident to the nourishment and growth of the impregnated
ovum, through physiological intermittent congestion of the generative
system. Ten cases are reported in which the diagnosis had been made
early and subsequently confirmed.

The Diagnosis of Conception. In a monograph on the pregravidic
symptoms of pregnancy, Keiffer2 believes that what he calls the pre-
gravidic signs of conception may possibly be defined, and his clinical
evidence is of much value in relation to tubal pregnancy.

The diagnosis of uterine gestation is not easy until a period of six to
eight weeks has passed, although von Braun and Piskacek claim to
have diagnosed it in the first week by noting a more or less longitudinal
groove in either the front or back of the uterus. Dirner, of Buda Pesth,
also claims to have diagnosed pregnancy very early by this sign. It
is Keiffer's belief that definite signs are associated with the rupture of
a Graafian follicle and the passage of an impregnated ovum along the

1 Journal of the American Medical Association, 1904, vol. xlii. No. 8.

2 Les Symptoms Pre"gravidiques, Bull, de la Soc. Belg. de Gyn. et d'Obstet., 1903, 1904,
vol. xiv., No. 2. ; British Medical Journal, December 12, 1903.

190 OBSTETRICS.

Fallopian tube. He believes sensations of slight pelvic discomfort,
usually not severe enough to require medical advice, accompany these
phenomena. At times these symptoms are severe, but an incorrect
diagnosis of a pathological condition is then made. Three cases are
reported in which sudden pelvic pain and very distinct swelling of one
or both ovaries occurred. In two instances swollen Fallopian tubes
could be detected, in another there had been inflammation of the tabes,
which had subsided, but was supposed to have recurred. One patient
had uterine hemorrhages with spasmodic pain. In all three cases a
normal pregnancy followed the attack of pain, accompanied by tubal
and ovarian swelling. He makes the observation that the ovary is
much enlarged when the follicle due at the period is ripe, and that
possiblv the sharp pain signifies muscular contraction of the tube, and
that this pain is possibly sharper if the ovum has become impregnated.
Hemorrhage, it must be remembered, is also a tubal sign, and may be
the cause of the false periods which mislead women in reckoning their
own pregnancies. Hot douches and other local therapeutic methods
are interdicted for sudden attacks of ovarian swelling and pelvic pain.
For as these symptoms may mean pregnancy, may not the great
increase in the number of extrauterine pregnancies during the
last twenty years be due in part to too hasty "uterine therapeutic
measures" for a purely physiological condition, thereby causing the
oosperm to be arrested in the tube, with the eventual result of a tubal
pregnancy ?

Diagnosis of Twin Pregnancy. The diagnosis of twin pregnancy
is always difficult and at times well-nigh impossible. Hydramnios
and a large fcetus are to be excluded, as they are the conditions espe-
cially likely to be confounded with it when there is such a degree of
tension in the abdominal walls as to render palpation difficult. Lermo-
vitch1 says that the round ligaments, being likewise included in the
physiological enlargement, can be felt as two bulky cords, one on each
side of the uterus at or slightly below the level of the umbilicus.
When there is a single foetus the enlargement of the uterus takes place
in the long diameter, and the normal relations of the round ligaments
are not disturbed. In twin pregnancy the uterus is chiefly enlarged in
its transverse diameter, causing a separation of the two layers of peri-
toneum which envelop the round ligaments, thereby effacing them to
such an extent that they are imperceptible to palpation, or may with
difficulty be felt as two small lax folds. The writer says that the pres-
ence of a tense, round, projecting ligament, extending on each side of
the umbilicus for one or two inches below it excludes the diagnosis of

1 La Semaine Med., October 7, 1903.

PREGNANCY. 191

twin pregnancy. Hydramnios does not impair the value of the sign.
In a single pregnancy the ligaments may be felt ; in a twin pregnancy
their palpation is more difficult or impossible.

Procreation of Sexes according to Will. D. Haenens1 calls atten-
tion to the observations and experiments made by F. Guiard to prove the
procreation theory of Professor Thury, of Geneva, who says that the sex
is determined by the stage of evolution of the unfertilized ovum in rela-
tion to the fusion of the male element. If the spermatozoid meets the
ovum before it has reached a certain degree of maturity the result will
be a female embryo; if the ovum is fertilized after it has passed a
certain degree of maturity the resulting embryo will be a male. A
great agriculturist experimented on cows in order to test the accuracy
of this theory. If he wished a female calf he put the bull to the cow
on the first day of her rut ; if he wished a male he put the bull to the
cow on the third day of her rut. Out of twenty-nine experiments the
sexes came as desired in the whole twenty-nine cases. Similar success
was obtained in experiments on sheep. At the Agricultural Insti-
tue of Proskau ten cows were put to the bull on the first day of the
rut ; of these, five had heifer calves and five had bull calves. Six cows
were put to the bull on the second day of their rut ; five of them gave
birth to bull calves and one to a heifer calf. It is generally accepted
that the more active period of fertilization in the human subject is the
four or five days following menstruation. It is equally certain that
fertilization may occur a few days before menstruation, during men-
struation, and up to ten or twelve days after its cessation, so that there
are practically fifteen to twenty days during which fertilization may occur.
Such a period permits of a perfect maturity of a shed ovum. The
assumption is that if fertilization occurs three or four days before the
period, the result in all probability will be a girl ; and if fertilization
occurs three or four days after the period the result will in all proba-
bility be a boy. It is necessary for the testing of such a theory that
only one act of sexual intercourse should be permitted, or that such inter-
course should be confined to a single day.

Guiard claims to have had exact experiments in thirty-five cases.
In thirty-one of these the law of Thury was proved. In the other four
sufficient precautions were not taken in the direction of a single inter-
course to make the result reliable. It must be remembered that sper-
matozoa can survive for four or five days in the female generative
passages, and in this way considerable miscalculation may occur. If such
a theory is correct it is needless to point out that underlying it is a very

1 Le Progres Medical Beige, September 15, 1903 ; Journal of Obstetrics and Gyne-
cology of the British Empire.

1 92 OBSTETRICS.

important social question, full of the most practical interest, not only
to parents bul also to the State.

In tlie same article the special resemblance of a child to one or other
parent is dealt with, and a theory to explain it is propounded. From
what has already been said the law of Thury claims that the unfertil-
ized ovum has a female (or early) phase, and a male (or late) phase of
evolution. The exact point where the female phase passes into the
male cannot be exactly determined. Now, if the spermatozoa reaches the
ovum very early in its female phase it will, of course, be a daughter,
hut that daughter will resemble its father, because the maternal part is
not so developed when fertilization occurs. If fertilization occurs late
in the female phase the daughter will partake more of the character-
istics of the mother. Similarly, if fertilization occurs early in the male
phase, the resulting boy will resemble his father, and if occurring late
in the male phase the boy will resemble the mother.

Pregnancy during Lactation. These two conditions, while not
occurring as frequently as ordinarily supposed, should, nevertheless, be
carefully guarded against. H. M. Church1 has observed this condition
in 30 out of 1000 obstetrical cases. In these cases the nursing child
becomes delicate and sickly, and usually at some time suffers from some
nervous affection or becomes the mentally weak one of the family. The
tendency is to premature expulsion of the embyro ; should the pregnancy
go on to full term the child will be born in many cases with a lowered
vitality. In the case of the mother there is greatly lowered vitality,
with a general undermining of her health, persisting for a longer or
shorter period, dependent upon the management of the case. When a
diagnosis of pregnancy is made during the period of lactation, the nurs-
ing child should be immediately weaned. A greater change occurs in
the mother's milk when a new pregnancy is established than occurs
after the establishment of menstruation following a pregnancy.

The author gives a detailed report of ten cases supporting his con-
tentions.

A New Intoxication Theory of Hyperemesis Gravidarum. Behm2
reports six cases of hyperemesis successfully treated by high enemata
of normal salt solution, and discusses the etiology of this disease. He
believes it is due to a toxaemia wdiich cannot arise from fetal metab-
olism because the symptoms appear early iu pregnancy when the foetus
is small, and disappear, as a rule, as the fetal bulk increases. Since
the termination, artificial or natural, of the pregnancy ends the vomit-
ing, as a rule, he believes that the toxin must originate from the extra-

1 Edinburgh Medical Journal, September, 1903.
5 Archiv f. Gyniikol., 1903, Band lxix., Heft 2.

PREGNANCY. 193

fetal portion of the ovum — from the placenta and membranes. Metas-
tases of the chorionic epithelium have been frequently described in
recent years, and the author regards this occurrence as almost physio-
logical, and suggests a syncytial intoxication as a cause of the vomiting
of pregnancies. He would exclude from this etiology those cases (a) in
which vomiting begins in the last half of pregnancy ; (6) those in which
the vomiting persists after the termination of pregnancy ; and (c) those
in which vomiting ends with pregnancy but the disease continues to
progress to a fatal termination. I have frequently observed the good
result of intestinal lavage for various manifestations of the toxsemia of
pregnancy, and it has come to be a routine practice to invariably employ
this measure in all cases of excessive vomiting. For the cases associated
with hysteria, isolation and intestinal lavage have been almost uni-
formly successful.

Incarceration of the Retrofiexed Gravid Uterus. Before attempt-
ing manual replacement of an incarcerated, retrofiexed gravid uterus,
colpeurysis, which W. Albert1 thinks the best means, should be tried.
This procedure avoids the pressure on the uterus, always required in
manual reposition, likewise the dangers of pulling down the cervix with
forceps, and detachment of the placenta, leading to abortion and death.
The bladder should be catheterized and the rectum thoroughly emptied
by a warm soap-and-water enema. A Brauns rubber colpeurynter is
then introduced well up into the vagina and gradually filled with boiled
water, the amount dependent upon the size and dilatability of the vagina.
The most Albert used in any case was twenty-one ounces. The uterus
is gently raised as if on a water-cushion, the time required being usually
from one to two hours ; but it is well to leave the bag in position until
the following day. There is no advantage in placing the colpeurynter
in the rectum or in using mercury to fill it. The subsequent treatment
when the displacement is corrected consists in wearing a pessary up to
the end of the fourth month of pregnancy, and frequently reclining
during the day, either in the lateral or prone position. In the later
months the bladder should be frequently emptied. The author reports
five cases successfully treated by this new method which offers a means
of treating this complication, less dangerous than prolonged and forcible
manual efforts to correct the displacement. The excellent results that
in recent years have followed prompt abdominal section would suggest
that Albert's plan of treatment might be instituted as the only prelimi-
nary treatment permissible in serious cases before or while preparations
are being made for a prompt release of the incarceration by section and
reposition of the uterus under the sense of sight as well as touch. Last

1 Munch ener med. Woch., March 24, 1903.
13

1 9 1 OBSTETRICS.

year I t< >« »k occasion to point out the excellent results of section for a fixed
retroflexed gravid uterus, both as regards the prevention of abortion and
the dangers of peritonitis following too strenuous efforts at reposition
by vaginal taxis.

Pregnancy and Abortion Late in Life. The possibility of preg-
nancy late in life should be borne in mind in some cases of suspected
cancer of the uterus and deciduoma malignum in elderly individuals.
Geyl" reports a ease of abortion occurring in the patient's fifty-sixth
year, not recognized by either the family physician or the consultant.
She had been married thirty-eight years, and had borne sixteen children
and had had three abortions. The last pregnancy occurred after her
forty-ninth year. Her periods were normal and regular until her fifty-
third year, when they became irregular, and in March of the following
year were missed altogether. She had no period until the. following
June, when a profuse hemorrhage occurred ; this was followed by a fetid
discharge and high fever. An examination revealed a large, soft uterus,
with a short, flabby cervix, within the cavity of which was contained a
soft, irregular mass. The uterus was vaporized on account of the great
fetor, and several days later removed. The patient ultimately recov-
ered. Geyl was greatly surprised to find that the mass contained in the
uterus was placental tissue. In this diagnosis he was confirmed by
Treub, of Ley den, and Van der Hoeven, who examined microscopic
sections.

Several cases of late pregnancy are reported. One woman gave birth
to her twenty -second child at the age of sixty-three years ; another be-
came pregnant shortly after her marriage, at the age of fifty-one years.
Rodsewich reported ten cases delivered between the ages of fifty and
fifty-five years.

Chorea in Pregnancy. That a woman's power of emotional control
is diminished during pregnancy partially explains the development of
a disease usually confined to childhood. Wall and Andrews2 present a
series of forty cases in thirty-seven patients seen at the London Hos-
pital, and discuss the causes and treatment of this condition during
pregnancy. That the cases were true chorea was attested by the fact
that the type of movements was indistinguishable from that of Syden-
ham's chorea.

The predisposing causes in pregnancy closely resemble those in child-
hood, and include rheumatism, previous attacks of chorea, and the
instability of the controlling centres. In one case it was due to nial-
development ; the patient was microcephalic and of an epileptic mother ;

1 Zentralb. f. Gynlik., 1903, No. 23.

2 Journal of Obstet. and Gyn. of the British Empire, June, 1903,

PREGNANCY. 195

there was no personal or family history of rheumatism. The determin-
ing causes are worry, due to illegitimacy of the child ; fear of a difficult
labor or of increasing an already large family, and shock. Five of the
forty cases died ; in three abortion or premature labor was induced,
and two aborted spontaneously. Those which spontaneously aborted,
and two of the three in which labor was induced, died. Here it may be
observed that the proportion of those spontaneously aborting (5 per cent.)
is lower than spontaneous abortions in normal pregnancy (16 per cent.).
The development of chorea very late in pregnancy in part explains this ;
yet, as the proportion is so small, it would seem that there is no great
tendency to spontaneous termination of pregnancy.

The mortality reports in this series of cases after the induction of
labor, also in those of other authors, have been such as to render this
procedure inadvisable, and it has been discontinued at the London Hos-
pital since 1895. The treatment consists for the most part in ensuring
rest and quiet, in good, nourishing food, especially carbohydrates, and in
good nursing. The bromides and opium are both considered dangerous
if given in doses sufficiently large to be effectual. Chloral hydrate and
chloralamide given in small doses and infrequently repeated were consid-
ered the most satisfactory hypnotics. Alcohol is useful, but should not be
given when a systematic course of arsenic is being administered. Under
such a course of treatment the prognosis is good for the life of the patient
and for the continuation of the pregnancy to term. The serious cases
of chorea complicating pregnancy which have come under my observation
have impressed me with the conviction that an element of toxsernia
exists in this disease occurring in pregnancy. In addition to the usual
treatment, efforts at elimination have always been useful. Intestinal
lavage, diet, laxatives, especially calomel and saline waters, have been
beneficial.

Myasthenia Gravis and Pregnancy. The literature of this disease
in association with pregnancy is reviewed by Kohn.1 He also reports a
case of his own. The patient was twenty-seven years of age, a multip-
ara, and was seen first at the fourth month of her pregnancy. Since
the birth of her last child, fourteen months previously, she had com-
plained of great weakness, giddiness, and faintness after the slightest
exertion. After exertion when swallowing any liquid, it had to be done
very slowly lest it regurgitate through her nose. She had diplopia
after using her eyes a short time, and could not entirely close her
eyelids. There were also severe frontal headaches radiating back to the
occipital region. She had all the characteristic signs of myasthenia
gravis, and gave the reaction. Her previous history was that on two

1 Prager med. Woch., May 14, 1903.

196 OBSTETRICS.

occasions, ten years and six years previously, she had suffered from
similar symptoms, when she had attacks of fainting which lasted over
an hour. In these attacks she was unconscious and bit her tongue.
Examination revealed unimpaired vision and normal retinse. There
was no reaction of degeneration or atrophy of the muscles. After five
days in bed the "myasthenic reaction" disappeared. Pregnancy termi-
nated in a normal delivery of a living child ; but two days after delivery
she became very weak. Her pulse was feeble, and the breathing stertor-
ous. Death ensued the same day. The history and the mode of death Kohn
considers a characteristic clinical picture of myasthenia gravis. The two
previous attacks of unconsciousness and biting of the tongue, he thinks,
probably were epileptic fits, though there is no record of the association
of epilepsy and myasthenia gravis in medical literature. Pregnancy had
a distinct influence upon this case and an important bearing upon its fatal
termination. In a previous case the patient died during pregnancy,
and in another all the symptoms appeared suddenly after delivery. In
other pregnancies in these same cases no effects were apparent. The
prognosis of myasthenia gravis is rendered more grave by conception ; as
regards the child it is favorable.

Extrauterine Pregnancy. The literature on this subject during the
past year has served to convince one of the importance of early opera-
tion by the abdominal route, while pathological investigations have served
to make clearer the mechanism of rupture. The process in some cases
is rather one of erosion. The impregnated ovum early burrows through
the mucous lining of the tube, leaving the lumen of the latter, and, dis-
tending and eroding the musculature of the tube, finally penetrates
the muscular wall of the tube and its contained bloodvessels, producing
slow and recurrent or suddenly rapid and profuse hemorrhages. This
mechanism explains some of the clinical symptoms more satisfactorily
than heretofore.

An interesting case of early rupture, on the nineteenth day, is re-
ported by Duncan,1 and one case going to term (the fifth such case
recorded) is reported by Freund.2 Duncan's case of tubal pregnancy
ruptured on the nineteenth day after conception and ten days after curette-
ment for menorrhagia, when the patient suddenly collapsed, and was pulse-
less and semiconscious from profuse internal bleeding. Salt solution was
transfused, and the abdomen was opened and found filled with blood
and some clots. In the left tube a small round perforation of the
slightly thickened tube was found near the uterine ends. The speci-
men showed the gestation sac wholly removed from the lumen of the

1 British Gynecological Journal, May, 1904.

2 Beitriige z. Geb. u. Gyn., Bd. xviii., Heft 1; British Gynecological Journal, May,
1903.

PREGNANCY. 197

tube. The sac had burrowed through the epithelial lining of the
tube into the muscular coat, and the opening through the former had
closed. It is now believed that this mechanism of the production
of hemorrhage is very common and that the tube is not ruptured by
overdistension, as formerly thought.

Freund's patient was twenty-eight years of age, and a diagnosis of
extrauterine pregnancy of ten months had been made. Operation
revealed the fetal sac in the left adnexa. On account of many old
adhesions it was impossible to entirely remove it. However, the
patient made a good recovery. The child showed maceration in places,
and weighed 4150 grams. It was 552 cm. in length. The placenta
was doubled over all around its maternal surface, and in shape resem-
bled a mushroom hat, a condition which Freund explains by the inser-
tion of the placenta being directly upon the mesosalpinx. The pedicle
of the placenta was therefore formed by a portion of the tube wall
particularly well supplied with bloodvessels, under which condition a
healthy normal woman might go to term. Freund believes that where
mummification and calcification of the entire ovum takes place the
earlier these changes occur the richer is the ectopic sac in connective
tissue and the adhesions in bloodvessels.

The Fcetus Retained in an Extrauterine Sac. An interesting
case is reported by Demelin and Bouchacourt.1 The patient was
thirty-eight years of age, and this was her sixth pregnancy. She was
admitted in the eighth month of her pregnancy, supposedly suffering
from an attack of peritonitis or gallstone colic. In a short time these
symptoms subsided, also the signs of commencing labor, and she was
allowed to go home. Upon examination a tumor distinct from the
fcetus was palpated, and was diagnosed as a subperitoneal fibroid. She
was visited later at her home, to obtain the subsequent obstetrical his-
tory, when it was found she had been ill for some months, and had
then gone back to her work. At this time the abdominal tumor was
much smaller. She was then exhibited at one of the Paris medical
societies as a case of extrauterine pregnancy, and the unanimous opinion
was in favor of expectant treatment. Some years afterward peritonitis
developed, and a laparotomy was performed. The sac was " marsupial-
ized " and drained. She made a good recovery. The foetus was almost
full term, and had remained in the sac four years. The literature of
the subject was discussed fully, as also was the treatment. Early opera-
tion was favored, as in the absence of old adhesions the operation is less
difficult, and there is a greater likelihood of being able to remove the
sac completely.

1 L'Obstetrique, November, 1903.

298 OBSTETRICS.

The Management of Pregnancy Complicated with Uterine
Fibroids. One of the most interesting questions in obstetrics is the
interaction between pregnancy and fibroid tumors of the uterus and
the proper management of this condition when so complicated. From
the discussion of Dr. A. Routh's paper1 before the British Medical Asso-
ciation we glean the following : Before antiseptics were introduced the
mortality of pregnancy complicated by fibroids was very large, both for
mother and foetus. The maternal mortality in five different series of
cases varied from 30 to 54 per cent,, while in the same series the lowest
fetal mortality given is 57 per cent, and the highest 66 per cent. The
dangers during pregnancy are rapid enlargement, with its consequences,
degeneration, abortion, hemorrhage, and sepsis. During parturition
the dangers are fetal malpresentation, obstruction, and hemorrhage.
In the puerperium we may have degeneration or extrusion of a sub-
mucous fibroid, sepsis and infection of the fibroid secondarily. Modern
aseptic and surgical methods have greatly reduced the mortality.
Pinard reports eighty-four cases with a fetal mortality of 23.6 per
cent, and a maternal of 3.6 per cent. Fibroids generally increase in
size during pregnancy, though there might be little increase in the
individual fibroids. Donald describes cases where the great increase
in size led to serious pressure symptoms on the diaphragm, and also
caused albuminuria. The blood supply would undoubtedly have much
to do with the size, and this would vary relatively to the position of
the placental site and the growth.

During involution marked atrophy occurs in some cases, especially
if there has been growth and softening during pregnancy. It is only
temporary in some cases, returning to its former size after a short time.
Frequently the intramural variety tends to get driven outward and become
subserous during involution. After labor a submucous fibroid occa-
sionally tends to degenerate, and may become necrotic. It may be
extruded into the uterine cavity, become necrotic and slough, and, being
unable to escape, set up a septicaemia or saprsemia, and cause death.
The softening which fibroids undergo in pregnancy renders them very
liable to infection, and submucous or more distant fibroids may become in-
volved, ending fatally. While there is some question as to whether fibroids
cause sterility, the general consensus of opinion favors the affirmative.
It must be remembered, however, that pregnancy would normally be less
frequent at the age when fibroids are most common. Also taking into con-
sideration that the average age of patients in 109 cases of Porro's, in
which fibroids complicated pregnancy, was thirty-five years, thus lessen-
in^ the possible chances of coexistence, it seems somewhat doubtful that

1 British Medical Journal, October 3, 1903.

PREGNANCY. 199

fibroids do cause sterility. Tubal gestation is extremely rare in a fibroid
uterus. While fibroids probably do uot predispose to abortion or
premature labor, it is held by some authorities that labor may come on
a week or two before full term. Statistics show that the proportion of
abortions with fibroids is very little greater than the normal average,
which varies from 20 to 25 per cent. That fibroids cause fetal mal-
presentation is unquestionable.

In fibroids with pregnancy, as a rule, labor is delayed, due to irreg-
ular uterine muscular contractions caused by the interstitial fibroids,
which render it impossible for the different groups of muscular fibres
to act co-ordinately. Post-partum hemorrhage is more frequent than
in normal labor. The placenta may also be adherent, requiring manual
removal, a dangerous procedure. This placental adhesion is also often
physiological, for if the placenta be attached over a subjacent fibroid
efficient retraction of the placental area is impossible. The question
whether fibroids will obstruct labor is a serious one. The fibroid may
be spontaneously lifted out of the pelvis by its steady growth, or this
may even occur during the progress of the labor. The prospect of
obstruction depends upon the position of the fibroid. If it grows from
the fundus or body, unless it has a long pedicle, there will be no obstruc-
tion. If it grows from the anterior part of the supravaginal cervix, there
is rarely obstruction. If the fibroid grows from the posterior supra-
vaginal cervix, obstruction may readily follow, for the fibroid is likely
in its growth to be arrested below the sacral prominence. These
fibroids occasionally become adherent to the pelvic floor, and are as
immovable as intraligamentous fibroids. The cervical variety are the
most obstructive, and, like the intraligamentous, cannot be pushed up
from below, nor are they spontaneously lifted out of the pelvis.
Fibroids retard, but do not impair involution. The lochia is more
profuse and lasts longer ; quite severe " after-pains " persist for a
week or ten days after labor. The real danger is that the uterus may
become septic, the fibroids become infected, and a fatal peritonitis
result.

In the treatment, if the patient is first seen before fetal viability and
obstruction seems probable, gentle attempts by digital or hydrostatic
pressure may be made to elevate the fibroid, using the Sims or knee-chest
position. Forcible attempts at reposition are to be avoided, as they may
result in torn adhesions or bruising of the fibroid. Failing to elevate the
tumor, use chloroform or the A. C. E. mixture, and avoid deep anaesthesia,
having the foot of the patient's bed elevated to assist the manoeuvre.
Intraligamentous and cervical fibroids cannot be reposited. Abortion
should be definitely abandoned. It is very difficult to induce it, should
the os be nearly out of reach, and then the uterine cavity may be so

200 OBSTETRICS.

distorted as to render delivery of the placenta impossible. The easier
it is to induce abortion the less necessary it is to interfere at all. In
the absence, therefore, of urgent symptoms, adopt an expectant attitude
ami await spontaneous labor at full term, giving such assistance as may
then be needed, and such treatment to the fibroids as is then indicated.
Should one of the emergencies discussed arise, then the choice of ab-
dominal operations would lie between a myomectomy and hysterectomy.
Should pressure symptoms develop before fetal viability, myomectomy
is the ideal indication for treatment. And when celiotomy is performed
before full term this operation should be kept in mind as an alterna-
tive. Myomectomy, however, can only be undertaken successfully in
those cases where the fibroids are pedunculated, or, if sessile, not deeply
embedded. It should only be undertaken where all the fibroids can be
enucleated, and those fibroids with broad bases are not suitable for this
procedure, on account of the large cavity left, which it is very difficult
to close and keep closed, on account of the great tension present.

Myomectomy has the advantage that, should enucleation fail, the
operator can proceed to hysterectomy. Abortion is more frequent after
the removal of sessile than pedunculated fibroids. In thirty-three cases
collected by Staveley since 1894 the mortality was 25 per cent. Hys-
terectomy, before fetal viability is indicated in incomplete abortion,
intractable hemorrhage, sepsis, serious pressure symptoms, and where
there are multiple fibroids too deeply embedded to allow of myomec-
tomy. But no operation should be performed before fetal viability
unless imperatively demanded by urgent symptoms. Lewers cites
cases and proofs in affirmation that cases during early pregnancy with
fibroids often complain of severe pain, but with suitable treatment it
will greatly lessen or may entirely disappear in a few weeks. In
patients first seen after fetal viability the indication is again to adopt
an expectant treatment so long as there is no danger to the mother.
Reposition of an obstructing fibroid may be tried at any time up to
full term, and cases are recorded where they have been successfully
reposited during labor. He emphasizes the fact that no attempt should
be made to drag a living or mutilated child past an obstructing fibroid,
by forceps, or version, so great is the danger to the mother. When the
patient is in labor, and the fibroid shows no tendency to rise, or is fixed
in the pelvis, an abdominal section is necessary, unless it be of the
cervical variety. In the latter case if the cervical fibroid be the only
one present its enucleation may be tried and, if easy, persisted in. At
full term vaginal enucleation should be followed by delivery by version
or forceps, and Cesarean section only performed when serious difficulty
or hemorrhage arise. In all cases, if possible, postpone the operation
until fetal viability. Where it has been decided to open the abdomen

PREGNANCY. 201

at full term for fibroids, Cesarean section should be the first step. It
should, if possible, be done at a selected date a few days before labor is
due, but the operator should be prepared for an operation should labor
be anticipated, as it often is. After Cesarean section has been per-
formed the remaining treatment will depend upon the circumstances.
The author believes conservative Cesarean section is only justifiable where
the operator does not feel himself able to proceed with a hysterectomy
or when the patient is in extremis or near the menopause. It has been
done successfully, but the disadvantages, apart from leaving the fibroid
in situ, are primary and secondary hemorrhages, sepsis, and secondary
infection of the fibroid. Degeneration changes may occur in fibroids if
the sutures are placed too near them. Sterilization by removal of both
ovaries is not advocated, nor would attempts at sterilization by removal
of portions of the Fallopian tube be indicated. Myomectomy is done
before fetal viability, to allow gestation to proceed and save the child's
life if possible. At full term this indication does not exist, but should
one be able to remove all the fibroids by a myomectomy adopt this
treatment, but precede it by a Cesarean section to avoid muscular effort
in the uterus. Should myomectomy be found insufficient on further
procedure, proceed to do a hysterectomy. Three methods of hysterec-
tomy are considered : 1. Porro's operation : supravaginal hysterectomy
with extraperitoneal treatment of the stump, only now done in the event
of uncontrollable hemorrhage, to save time if " shock " were very great,
or possibly in sepsis, as an alternative to panhysterectomy. 2. Baer or
Chrobak's operation : supravaginal hysterectomy with retroperitoneal
treatment of the stump. 3. Panhysterectomy (Doyen). This opera-
tion, as opposed to the supravaginal one, seems to be absolutely indicated
in comparatively few cases — i, c, uterine sepsis, unhealthy cervix, or
where cervical fibroids are present, together with others, in the body of
the uterus. Spencer prefers panhysterectomy to supravaginal for fibroid
uteri, even when complicated by pregnancy, because he believes there
is less risk of secondary hemorrhage, no risk of sloughing of the cervix,
better vaginal drainage, and therefore less risk of infection of ligatures
and no chance of sarcomatous or cancerous growth in the stump. If it
were proved that the portion of cervix left was liable to a malignant
degeneration, as is claimed by some authorities, then there would be
strong reasons for panhysterectomy. Statistics show that apart from
those cases where it is definitely indicated panhysterectomy may be as
safely performed as any supravaginal operation, and the choice of opera-
tions can be left to the operator. Cumston says dyspareunia and severe
dragging pains during and after defecation follow panhysterectomy, due
to adhesions forming at the vaginal cul-de-sac and between the vaginal
vault and bowel. The mortality of Cesarean hysterectomy by all

202 OBSTETRICS.

methods, at or near full term, for pregnancy complicated by fibroids
has dropped from 75 per cent, in 1880 to about 20 per cent, in the -last
ten years. Where labor has spontaneously occurred in fibroid uteri, or
where no radical operation has been done, post-partum hemorrhage and
sepsis may occur. If the hemorrhage cannot be controlled, hysterec-
tomy may be necessary. In case of sepsis seen soon after the patient
becomes infected, empty the uterus of all blood clot or retained debris,
douche with iodine and water, and swab the endometrium with a strong,
iodine solution (1:4). Curettage should uot be employed. Should
this fail to reduce the temperature, or if the uterine cavity cannot be
satisfactorily explored on account of an obstructive fibroid, hysterectomy
should be performed. The longer hysterectomy is postponed after
sepsis has declared itself, in the presence of fibroids, the less likely is
the patient's recovery. Several cases are reported successfully treated
by this procedure. Sloughing fibroids after labor treated by myomec-
tomy have nearly all proved fatal. Hence if radical treatment be
adopted the more radical the better. It would seem that any form of
hysterectomy is better than myomectomy, and panhysterectomy is to be
preferred to the supravaginal form.

The comprehensiveness of this subject would seem to preclude the
formation or attempt to follow any definite rules as to treatment. Each
case should be treated as circumstances and surroundings require, and
upon its own merits, remembering the latitude offered us in the selec-
tion of appropriate treatment.

My belief is that conservatism should characterize our treatment of
fibroids complicating pregnancy and labor, but upon the very first
evidence during labor of serious obstruction, then conservatism means
radical surgery. Hysterectomy under such circumstances is really
more conservative than myomectomy, since it will save more lives.

Fibroid of the Cervix Obstructing Labor. A case in which a
fibroid of the cervical variety projected into the vagina and obstructed
labor is reported by Bohuke.1 The patient had been flooding for two
weeks, and was sent into the hospital for this condition. She was
twenty-eight years of age and in the ninth month of her sixth preg-
nancy. Strong pains had set in upon her removal to the hospital, and
upon examination a soft, solid tumor about the size of man's head was
found projecting through the dilated cervix into the vagina. The
fetal head, presenting immediately behind it, was prevented from fur-
ther descent, and labor could not proceed. Bohuke found that the tumor
had partly detached itself from its attachments, but was still adherent
to the left side of the cervical wall. He succeeded in enucleating it,

1 Monats. f. Geb. u. Gyn., May, 1903.

PREGNANCY. 203

which procedure was followed by so much hemorrhage that it was
necessary to turn and extract the child. The child was born alive.
The cavity left by the enucleation of the growth was firmly packed with
gauze. Two weeks later it was about the size of a hen's egg and the
patient was doing well. The fibroid weighed two and three-quarter
pounds, and measured over seven inches in its longest diameter. It had
undergone necrotic changes in its centre.

Eclampsia. The exact nature of the cause of puerperal eclampsia
is as yet oue of the unsolved problems. Whitney and Clapp1 pre-
sent the results of experimental work done by them in an effort to
advance our knowledge in this direction. Formerly the underlying
factor in the production of the disease was sought in a lesion or ineffi-
ciency of the kidneys ; recently, however, the changes in the urinary
tract have come to be regarded as a secondary, but by no means con-
stant, sequel of some unknown toxic agent or agents circulating in the
system. While it is admitted that renal lesions are found in the great
majority of eclamptic cases, their absence being exceptional, at the same
time they are often so slight as to be of little clinical significance. On
the other hand, Fehling found that in women suffering with chronic
nephritis less than 5 per cent, of his cases developed eclampsia. The
theory has gradually gained ground that eclampsia is due to an auto-
intoxication, while the theory that it is an intoxication due to retention,
the result of renal insufficiency, has lost ground. A certain amount of
nitrogen is retained normally in the body, resulting from the growth of
the child, placenta, and uterus. So, in attempting to demonstrate that
a decreased excretion is indicative of approaching eclampsia, it must be
remembered that its estimation can only be approximated after making
allowance for the amount retained physiologically, which varies in dif-
ferent individuals. It is yet a question whether the toxic substances
which cause eclampsia are of fetal or maternal origin.

In studying the role of ammonia in the physiology and pathology of
the organism, the writers were impressed with certain analogies existing
between the premonitory symptoms of eclampsia and those produced
in animals having a Pawlow-Eck fistula, after feeding with large quan-
tities of proteid materials. The animals remain normal as long as they
are kept upon a restricted diet, consisting of milk, oatmeal, etc. ; but,
on the other hand, symptoms promptly appear after giving meat or the
amido-acids, such as glycocol, which, under normal conditions, are con-
sumed in the body without any abnormality. Shortly after giving such
substances the animals manifest great restlessness, ataxia, varying
degrees of amaurosis, rapid pulse and respiration, coma, and finally

1 American Gynecol., August, 1903.

204 OBSTETRICS.

death. At the same time the urine shows a decrease in the proportion
of urea nitrogen, and in most, but not all cases, an increased percent-
age of ammonia, while at autopsy areas of fatty degeneration are con-
stantly found in the liver and kidneys. Iu view of these considerations
it was thought of interest to determine whether changes could be detected
in the subdivisions of the urinary nitrogenous materials in eclampsia,
with the view of obtaining a clue as to the early diagnosis of this con-
dition, while at the same time light might be thrown upon certain patho-
logical conditions present.

The metabolism in three normal non-pregnant individuals was first
studied in order to compare it with the process in pregnancy. The
various nitrogenous subdivisions were then calculated in four cases of
normal pregnancy, both before and after delivery. Upon comparing
the various results it became evident that, although the changes were
not constant, there was an unmistakable tendency during pregnancy
toward a decreased output of urea nitrogen, together with a slight
increase in that of ammonia nitrogen as compared with the non-preg-
nant condition. The pathological material was derived from one case
of toxaemia of pregnancy and three cases of eclampsia. In the eclampsia
cases careful study shows clearly that the essential change consists in a
decrease of the percentage of nitrogen which is eliminated as urea,
together with an increase in the amount which is precipitated by phos-
photungstic acid and readily decomposed by heating with sulphuric acid
at a temperature of 160° C. Our knowledge as to the nature of this
latter class of substances is as yet, unfortunately, very incomplete.
In some cases the loosely combined nitrogen is undoubtedly derived
from ammonia, while in others it is to be attributed to some as yet
undetermined antecedent of urea. The variability in the increase of
ammonia is attributed to the imperfect oxidation of proteids ; in other
cases the ammonia is retained within the organism either in the body
fluids or tissues in excessive quantity, particularly in the nervous
system. The cause of these alterations which produce eclampsia may
be due to a relative insufficiency of the liver function during pregnancy,
to some digestive anomaly of the placenta or uterine wall, or it may
result from some abnormality in the metabolism of the foetus. Further
study and investigation are necessary to determine the value of these
findings in predicting eclampsia. Should they prove to be constant and
to occur some time previous to the onset of the eclamptic attack, they
will have great practical value in regard to the institution of the proper
treatment.

The more recent investigations of this disease have been along the
lines of disturbed metabolism and toxin absorption. The urinary secre-
tion, however, continues to be our most important clinical premonitory

PREGNANCY. 205

evidence. The placental origin of toxins and disturbances in the function
of controlling metabolism possessed by the thyroid gland have latterly
diverted attention from the theories of pressure at the pelvic inlet,
splanchnic nerve innervation, inactivity of the functions of the liver, and
autointoxication from intestinal absorption.

Lest we forget the important clinical association of kidney failure,
and to renew the importance of this practical phase of the subject,
B. C. Hirst1 discussed his conclusions arrived at after a practical ex-
perience with over one hundred cases. He said clinical experience throws
valuable light upon three phases of the subject — i. e., premonitory signs,
etiology, the preventive and curative treatment. He believed that
there were strong grounds for accepting the view " that the products
of fetal metabolism discharged into the maternal blood and eventually
eliminated by the maternal kidneys were the chief predisposing causes
of eclampsia, and that insufficient elimination by the maternal kidneys
is the chief exciting cause." Anything which causes the kidneys extra
work, such as a heavy nitrogenous diet, a sudden cessation of the nor-
mal bowel, skin, or kidney function, determined an eclamptic attack.
Eclampsia, as a rule, developed late in pregnancy with a living child.
The fact that it is ten times more frequent in twin pregnancies than
single favors the theory of fetal origin of the toxins of the disease.
There are exceptions to this general rule, but the writer believed it an
open question whether those cases occurring early were not ordinary
uremic convulsions, and cited a case under his care in support of this idea.
No view can be more harmful than that diseased kidneys or kidneys with
impaired function in pregnancy may be regarded with entire indifference.
Women with nephritis are disposed to eclampsia. It is abortion, mis-
carriage, and premature death of the foetus which prevent many of
them from arriving at the convulsive stage ; in other cases toxic symp-
toms appear early, are carefully treated, and either acquire a tolera-
tion to the toxins or call for an artificial termination of pregnancy.
Hirst's own experience has been that pregnant women with nephritis
or an hereditary tendency to nephritis almost invariably demand active
treatment to prevent a gestational toxsemia or a premature termination
of pregnancy, and that nephritis in pregnancy is one of the gravest
complications, and never to be regarded with indifference. Albumin,
in considerable and increasing quantities, found in the filtered urine is
regarded as the most important premonitory sign. While it is absent
in a few cases, there is no other symptom of a gestational toxaemia and
threatened eclampsia so constant and characteristic. In comparison

1 Proceedings Philadelphia County Medical Society, December 31, 1903, and February
29, 1904.

206 OBSTETRICS.

with it tlic area excretion is valueless, and an adherence to this test
of urea elimination as a sign of gestational toxaemia or threatened
eclampsia will only lead to error in diagnosis and treatment. In
examining the urine casts should be carefully searched for. As they
increase and decrease with the increase and decrease of the albumin,
however, the course of the albuminuria is a more reliable guide for
therapeutic indications. The impression given by much of the recent
literature upon this subject, that albuminuria is unimportant as a dan-
ger signal in pregnancy, Hirst decidedly opposes, and in contradiction
says : •' It is a clinical rule, with few exceptions, that albuminuria pre-
cedes the other signs of gestational toxaemia, that the gravity of the
woman's condition can be measured by the steady increase in the amount
of albumin in spite of treatment, and that a steady and rapid increase of
albumin is the most certain and constant premonitory sign of eclampsia
that we possess at present." The preventive treatment is based upon
kidney inadequacy, consisting in a milk diet, diaphoresis, diuresis, and
catharsis. Thyroid extract for this condition is still on trial, and it is
believed merits further consideration.

Certain disputed points in the curative treatment were discussed, the
most important being the obstetrical treatment of eclampsia in preg-
nancy and labor. While the writer had entered practice convinced
that the rapid evacuation of the uterus was the proper treatment, and
had twice subsequently reverted to this view, further experience has
confirmed him in the conclusion that it is erroneous. After extended
trials of both plans he is better satisfied with the treatment directed
solely to the eclampsia, without regard to the uterine contents until
such a degree of dilatation of the os is secured spontaneously that delivery
can be secured without violence.

In antepartum eclampsia the uterus should only be evacuated when,
despite treatment, the patient's urine is persistently albuminous and
filled with casts or other symptoms causing great anxiety continue. In
such cases it is best to induce labor slowly by bougies or the Voorhees
bag if possible, meanwhile actively employing the eliminative treatment
of diaphoresis, diuresis, and catharsis. Resort to a forced delivery only
when imperatively necessary. CaBsarean section is not approved of in
eclampsia. The treatment of the convulsions consists in elimination
and the stilling of nervous excitability and muscular activity. The
eliminative measures consist in normal salt injections, venesection,
sweats, and purgation. Diuretics are of no use, for during the attack
the kidneys are practically non-acting as excretive organs. The seda-
tive remedies are chloral and opium. Opium he is prejudiced against,
and believes that there is risk of poisoning the patient and combating the
eliminative treatment, which is the most important feature. Veratrum

PREGNANCY. 207

viride is used for relief of the arterial tension and spasmodic contrac-
tion of the arterioles. Hospital treatment by a thoroughly drilled staff
it is believed would reduce the mortality more than one-half.

Dr. James Tyson, in discussion, concurred in the etiology, and always
advised caution in the use of morphine in Bright's disease, because he
had seen uraemia precipitated by it. He said that morphine is mainly,
one might almost say, only dangerous in chronic interstitial nephritis.
The majority of cases of puerperal eclampsia are due to parenchymatous
nephritis ; hence in these cases morphine may be used with comparative
safety and brilliant results. But since interstitial nephritis is the cause
in some cases, risks are run if morphine is used indiscriminately. In
parenchymatous nephritis the renal epithelium is still capable of elimi-
nating morphine ; hence the safety in its use. However, in those cases,
more particularly those in which the nephritis has preceded the preg-
nancy, and the disease is interstitial, the use of morphine is attended
with large risk, and as a precise diagnosis is not often made, the safest
course is to get along without it, or defer it until other measures fail.
He believed in the eliminative treatment. It was necessary that sweat-
ing should precede hypodermoclysis to avert danger of overloading the
venous side of the circulation, and thus dilating the right heart. If
we first deplete by blood-letting or by sweating and purging, we make
room for the salt solution to be subsequently introduced. The depletion
removes a certain amount of the toxic matter, while that which remains
is further diluted by the salt solution. In the discussion of Hirst's
paper I agreed in the main with his statements, and while confident
that albumin in large quantities is a most valuable sign, albumin in
conjunction with increasing systemic conditions is a condition especially
to be considered. Cases in which there are large quantities of albumin
in the urine, unaccompanied by signs of toxaemia elsewhere, will fre-
quently go through pregnancy without trouble. These cases, seen occa-
sionally by the general practitioner, lead him to believe albumin alone
is not dangerous. The toxaemia is sometimes shown before large quan-
tities of albumin appear, by attacks of hebetude, neuralgia, headache,
nausea, and vomiting after the period when the physiological nausea and
vomiting should cease. At other times the nervous system is especially
affected, indicated by irritations of the peripheral or central nervous
systems, ptyalism, pruritis, incorrigible vomiting, insomnia, neuritis,
melancholia, and mania. The skin sometimes may bear the brunt of
the toxaemia, as is shown in herpes and bronzing.

The cardiovascular system should also be closely studied. I have
seen cases in which the first toxaemic outburst was manifested upon the
heart and circulation. The liver is also frequently at fault in elimina-
tion and its toxin-destroying function, and in the prophylactic treatment

208 OBSTETRICS.

of eclampsia its study goes hand-in-hand with that of the kidneys. I
have noticed that in toxsemia not associated with advanced Brieht's dis-
ease the prognosis for the induction of labor or for the result of medical
treatment is very much better than in toxaemia associated with advanced
kidney changes. The slow accumulation of toxins is more dangerous
and less responsive to prophylactic treatment than a rapid formation.
Plethoric cases with a full bounding pulse have responded most happily
to venesection. For rapid elimination I believe that Epsom salts have
proven most efficient in my hands, and 1 have never seen a case of
puerperal eclampsia die in which from twelve to twenty-four stools
could be secured in twenty-four hours. Rapid elimination by Epsom
salts, followed by hypoderrnoclysis or high enemas of salt solution, is
much more rapid and effective than sweating. Sweating helps, but not
to the degree of free purgation. Saline infusion should be used judi-
ciously, as harm may result from its indiscriminate use with no means
of its elimination. (Edema of the lungs and increased intracranial press-
ure are not uncommon sequels in cases flooded with salt solution when
neither venesection nor catharsis nor diaphoresis have been secured to
eliminate the salt solution, and with it the toxins.

Veratrum Viride in Puerperal Eclampsia. When the
eclamptic seizure occurs there are two indications, elimination and
sedation. J. S. Hammond1 controls the convulsions by chloroform
inhalations, then gives a hypodermic of ten to fifteen drops of tincture
of veratrum viride, and examines the bladder and rectum to note whether
they are empty. The veratrum viride should be repeated at twenty-
minute intervals until the pulse is under 60. It also acts as a dia-
phoretic and emetic. The bowels should be moved either by one-quarter
grain of elaterium or two or three drops of croton oil given in olive oil.
Hypoderrnoclysis should be used to promote diuresis. Obstetric inter-
ference is not justifiable, for although the child may be the predisposing
cause, it is not the exciting one, and interference at this time would add
the dangers of traumatism and irritation to the already existing toxsemia.
Let nature deliver, whether the child is dead in the womb or not. The
latter advice is unduly conservative. So soon as the cervix is dilated
there is no good reason for further delay, since a simple forceps delivery
can never be disadvantageous to either the mother or child.

While veratrum viride is a valuable drug in many cases of eclampsia,
I am convinced that its indiscriminate employment in this disease can do
harm. I recall having seen a case in consultation in which veratrum
actually contributed to the fatal termination, the physician having freely
administered it to a woman pale, emaciated, with a rapid, feeble, and

1 Annals of Gvn. and Ped., June, 1908.

PREGNANCY. 209

compressible pulse — the very type of case which cannot withstand the
depressant action of this drug in the large dose it is necessary to use in
the treatment of eclampsia. The plethoric woman with a high tension
and steady pulse, even if very rapid, is the type of case in which vera-
trum will be most efficacious. One should not forget the depression
likely to follow the free use of chloroform and chloral and rapid
catharsis and diaphoresis. When veratrum in large doses is added to
this exhausting treatment in a patient profoundly depressed by her
toxremia, she must be of average sturdiness to withstand such heroic
measures. Veratrum finds its greatest usefulness in the class of cases
in which venesection is useful, and may be combined with or used to
supplement blood-letting.

Treatment of Puerperal Eclampsia by Thyroid Extract.
Thyroid extract is recommended by H. O. Nicholson1 in the treatment
of puerperal eclampsia, both as a prophylactic and after the onset
of convulsions. Nicholson's persistent employment of this treatment
has brought it deserved notice. As a prophylactic given in the pre-
eclamptic state he recommends its administration in small doses of five to
twenty grains in the twenty -four hours. The main object of the thyroid
treatment at this stage is to readjust the processes of nutrition so as to
more fully complete the metabolism of nitrogenous substances. This,
his experience has led him to believe, is actually accomplished. When
convulsions are present it is quite useless to give the extract in small
doses. Large doses must be given for the rationale — for its use is then
quite different. The urine is greatly diminished in quantity or
suppressed, and the chief aim of any treatment is to get the kidneys
secreting again. In the eclamptic state the condition of the arteries and
arterioles is one of profound constriction, with resulting rise in blood
pressure. It is the author's opinion that these circulatory features give
the clue to the only rational method of medical treatment. Vasodila-
tation is the principle of treatment indicated. Thyroid extract appears
to be an ideal vasodilator in cases of actual eclampsia ; but it is, then, as
a rule, absolutely necessary to use very large doses. Thirty or forty
grains may be given at the first dose, followed by twenty or thirty
grains in six or eight hours; if there are no signs of improvement he
would not hesitate to give even larger doses in a severe case if this
amount did not prove sufficient. The aim is to produce thyroid intoxi-
cation as rapidly as possible ; and less danger in his experience is
incurred by giving a few large doses than by a continuous administra-
tion of smaller quantities. Large doses of morphine produce the most
prompt and powerful vasodilatation one can employ. The simultaneous

1 Journal Obstet. and Gyn. Brit. Emp., January, 1904.
14

210 OBSTETRICS.

or subsequent use of thyroid extract seems to provide a most successful
combination of remedies for the purpose of rapidly re-establishing the
secretion of the urine.

The report of a case treated in this manner is appended. The patient
was twenty-one years of age and a primipara. She was admitted to
the hospital in the eighth month of her pregnancy with no apparently
abnormal symptoms, although it was noted her pulse was somewhat
-lower and of higher pressure than usual. Three weeks later, while
palpating her abdomen to locate the position of the foetus, it was noticed
that there was a marked degree of oedema of the abdominal walls and
the body generally. She was not ill, and had no headache or vomiting.
The urine was slightly less than normal in quantity ; specific gravity
L015, and no albumin. The pulse was abnormally slow and of
unusually high pressure, such as he has found invariably associated
with a greatly increased peripheral resistance. Pulse tracings showed
an exaggerated size and an unduly sustained character of the second
summit of the systolic wave ; also a variable duration of the dias-
tolic phases of the pulse curves. The presence of these characters in
pregnant women near the end of gestation strongly suggests impend-
in-- danger in the way of eclampsia. Sixteen days later she was drowsy,
had severe headache, dim vision, and several attacks of vomiting. The
following morning labor pains began, the membranes ruptured early,
vomiting continued, and the secretion of urine apparently ceased. The
evening of the same day an assistant found the patient semicomatose,
with strong pains and the os fully dilated. She had a severe eclamptic fit,
lasting about two minutes, followed by coma and stertorous breathing.
She delivered herself spontaneously fifteen minutes later, while still
unconscious. The placenta was expelled in about twenty minutes with
very little hemorrhage, as is usual in such cases. Immediately after-
ward she had another seizure. One-half grain of morphine was now
uiven hypodermically ; in one-half hour the skin showed signs of begin-
ning perspiration. One hour later she had a third convulsion, lasting
oue minute and a half, and less severe. Two hours later she was given
forty grains of thyroid extract. Her bladder was catheterized, and only
three ounces of urine withdrawn ; this became solid with albumin on boil-
ing. She slept fairly well that night, perspired profusely, and vomited
several times. The following morning her temperature was normal, pulse
i»2. She complained of much pain low down in her abdomen ; forty
ounces of urine were withdrawn from her bladder. At 10.30 a.m. thirty
grains of thyroid extract were given, the drowsiness gradually disap-
peared, and at 3 p.m. she passed thirty-five ounces of urine. At 8.30
p.m. she was quite conscious, and perspired freely, with a pulse of 115
and a temperature of 101° F. Her face was flushed, and she complained

PREGNANCY. 211

of headache, " evidently thyroidism." At 9.30 p.m. thirty ounces of urine
were passed, and at 10 p.m. a third dose of fifteen grains of thyroid
extract was given, making eighty -five grains in twenty-three hours. She
progressed uninterruptedly to recovery. The thyroid extract was con-
tinued in ten-grain doses twice daily for two days, then was reduced to
five-grain doses, and given twice daily for ten days. All the symptoms
disappeared rapidly and completely.

The Surgical Treatment of Eclampsia. The profession con-
tinues to be somewhat divided as to the surgical or obstetric treatment
of eclampsia. T believe, however, that the majority of those of widest
experience are averse to the opinion that the child should always be
delivered by the quickest possible means, and then should follow the
medical treatment. It has always been my practice and teaching to
discountenance that plan of treatment and to rely first upon active
elimination and combative medical treatment, and to interfere obstet-
rically only by the milder measures, to provoke or hasten labor, and to
deliver when sufficient dilatation of the cervix has thus been obtained.
Accouchement force, Bossi's dilator, Csesarean section, or craniotomy on
the dead infant I have resorted to in the past, but never with so good
results as have followed the less aggressive obstetrical treatment.
There are many obstetricians who follow the boldest surgical treatment,
and Caesarean section and Bossi's dilator have many adherents. The
latter instrument, judiciously used, represents the most aggressive surgical
treatment I ever employ, and this is reserved for rare cases and used
with caution, and with no effort to secure dilatation of the cervix under
a half hour.

E. Bumm1 believes that if prompt emptying of the uterus is undertaken
immediately after the first appearance of the convulsion, while the lungs
are free and the pulse is yet good, a favorable result always follows, and
the mortality of eclampsia will be reduced to about 5 per cent. When
patients are seen for the first time in the later stages of convulsions,
and where there are changes in the liver and kidneys, and probably a
hemorrhage into the brain, that patient is probably doomed, as but
little can be done in the way of treatment. If the cervix be completely
dilated, version, forceps, or, if necessary, perforation is indicated. Tf
it be partially dilated, further dilatation may be best accomplished by
combined version, pulling down a foot and allowing the breech to com-
plete the dilatation. He believes this procedure can be done as quickly
and with less danger than with the metal dilators. When the cervix
is closed and immediate delivery is indicated, vaginal Cesarean section
as devised by Duhrssen is preferred. The excessively high mortality

1 Munch, metl. Woch., May 2fi, 1903.

o 1 2 OBSTETRICS.

of the Saenger CsesareaD section has caused that operation largely to be
abandoned ; and the past year has found the adherents of Duhrssen's
operation more frequent.

Vaginal CjESareah Section in Eclampsia. From the results
obtained by the practice of Duhrssen's vaginal CsesareaD section upon
the following case, II. Salt1 recommends the operation in all cases of
severe eclampsia during pregnancy. The patient, aged forty-two years,
a multipara, was first seen in a deep coma in the seventh month of her
pregnancy. She had had swelling of the legs and headaches during
the pregnancy. On awakening that morning she found herself blind,
shortly afterward she lost consciousness, and developed severe eclamptic
tits. There were deep coma, cyanosis of the face, and stertorous respira-
tion. The os was tightly closed, and labor pains had not been observed.
In the three hours succeeding her admission she had five severe fits.
Her urine showed albumin up to three-quarters of the volume. There
was no sign of dilatation of the cervix, and operation was decided upon.
An injeetion of morphine was given. The cervix was grasped at each
side by volsella forceps, and the anterior vaginal wall was incised from
the cervix to the urethral orifice. Next the bladder was separated
from the anterior vaginal wall and from the cervix, and the anterior
uterine wall was cut through from the vaginal side as high as the point
where the bladder had been separated from the cervix. The sides of
the wound were then grasped in the forceps and the peritoneum pushed
on and upward out of the field. The incision in the uterus was then
enlarged sufficiently to allow the hand to be passed into the uterus.
The foetus was grasped by the foot, turned, and extracted. The pla-
centa had to be removed manually after waiting fifteen minutes. The
uterus was packed with iodoform gauze and the wound in the uterus
sutured. The vaginal incision was sutured and a piece of gauze pack-
ing inserted between the cervix and the bladder. The packing was
removed from the uterus on the second day. The wound healed by
first intention, and she was discharged well on the twenty-fourth day
following her operation. Her convalescence was rather a stormy one.
After delivery she remained comatose, and the following day had eight
eclamptic fits. Two days later the comatose condition disappeared, and
it was found she was suffering from a puerperal psychosis, with maniacal
attacks. This condition gradually disappeared. The writer claims
the following advantages for the operation : 1. It is less dangerous
than attempting to deliver by version or forceps when the os is tightly
contracted ; and it takes less time than dilatation. 2. It is easily and
quickly performed, and, since it is extraperitoneal, is to be preferred to

1 Deutsche med. Woch., July 23, 1903.

PREGNANCY. 213

ordinary Csesarean section, as there is less exposure to infection, and it
is accompanied by less shock. This report, it must be borne in mind,
is gleaned from experience in a single case, and the value of its testi-
mony in favor of the method of early and active evacuation of the
urterine contents must be considered from that point. The evidence
is in no way convincing that all cases of severe eclamptic seizure should
be treated by this method, but it is an interesting addition to the present
discussion of the treatment of this condition.

Treatment of Placenta Praevia. The treatment of placenta prsevia
is still a much mooted question. H. D. Fry1 emphasizes the point that
in considering the treatment the entire situation must be carefully and
intelligently considered before it is instituted. The death rate in pla-
centa prsevia is as much controlled by the variety of the complication
as it is by the method of treatment. Each case of placenta prsevia
must be treated on its own merits and according to conditions existing
in each particular instance. The tampon is the best method in some cases ;
the forceps in others. Podalic version and combined version both have
their indications, while Csesarean section has, perhaps, won a place in
a small proportion of cases. Modern methods have rendered valuable
aids to success. 1. The recognition that the uterus should be promptly
emptied in every case of placenta prsevia as soon as the diagnosis is
made. 2. The elimination of a great source of mortality by asepsis.
3. The adoption of bipolar version in certain cases. 4. Slow extrac-
tion of the child has much lowered maternal, if not fetal, mortality.

Prompt control of post-partum hemorrhage by packing with gauze
tampons and remedying the ill effects of hemorrhage by saline trans-
fusions are important aids in treatment. The writer believes that by
classing together all varieties of placenta prsevia and treating each com-
plication by the best modern methods we should reduce the maternal
mortality below 5 per cent. The conditions most favorable to success
in Csesarean section are only found in well-ordered and equipped hos-
pitals in the hands of experienced abdominal surgeons. Where such
help cannot be secured it is safer to entirely exclude the question of
Csesarean section in the treatment of placenta prsevia. In the hands of
the general practitioner modern methods will give the best results. The
fetal mortality varies from 50 to 60 per cent. This mortality is largely
due to the fact that many of the infants succumb on account of the
premature birth. Csesarean section would increase the chances for the
infant over birth by the natural passage. Hence in this small propor-
tion of cases Csesarean section is advisable. 1 . When the mother is in
good condition and not exhausted by labor or hemorrhage. 2. When

1 Maryland Medical Journal) July, 1903.

214 OBSTETBICS.

the placenta is implanted centrally or Dearly so. :',. When the cervix
is undilated and undilatable.

In a paper read by Dr. D. Longaker before the Philadelphia Obstet-
rical Society, June, 1 903, this subject was considered with special refer-
ence to combined version. Seventeen cases were seen, and all but two
treated by him. There was but one maternal death in the series. In
this case the placenta completely covered the os. The patient was a
multipara at full term, with moderate bleeding and the child presenting
transversely. The child was horn forty-five minutes after version, by
the mother's unaided efforts. No bleeding occurred until after the
manual separation of the markedly adherent placenta. In spite of an
intrauterine gauze pack, oozing continued, and death occurred three
hours later.

In these eases combined version yielded the best results in the earlier
ones ; in those from the earliest period of fetal viability to the thirty-
sixth week it acted as a most certain means of controlling hemorrhage
and stimulating labor pains. Including a case of twins, eight of the
eighteen babies were saved. In every one of the cases of combined
version near term the child was lost. Internal version afforded no
better results, and was only mentioned to be condemned.

Combined version, it is believed, is free from all danger if the rules
of Braxton Hicks be observed. The most important are to introduce
one or two fingers, turn, and wait. It would be more rational to pay
as little attention to the foetus in placenta praevia as in ectopic preg-
nancy, then the warning hemorrhage would be the signal for active
interference, and all cases would be treated actively in the realization
that the woman's safety lay in evacuation of the uterus. Of the seven-
teen cases reported, in ten the placenta was centrally implanted, in six
marginally, while in one its position was not stated. Combined version
was employed in twelve cases, internal version in three, and in two cases
the membranes were ruptured and forceps applied.

In the discussion Montgomery said that it was a question whether, in
a plan of treatment which produced a mortality of 55 per cent, for
the child, some other plan of treatment that afforded but little increased
danger for the mother and greatly increased opportunities for the child
should not be tried. He referred to Cesarean section, and believed that
in cases where the birth of a living child is of very great importance to
the parents, and where they are willing to take great chances, this
operative procedure should be offered them. The following points were
considered advantageous in operating : 1. The hemorrhages indicate the
character of the trouble and give the physician an opportunity to per-
form the operation under careful aseptic precautions. 2. He is able to
choose the time for the operation. 3. In those cases in which the cervix

PREGNANCY. 215

was rigid and dilatation likely to be slow and difficult, Csesarean section
would afford the mother an increased advantage. G. M. Boyd agreed
as to the necessity for a careful study and diagnosis in ante-partum hem-
orrhage, for upon this often will depend the successful treatment. In
central placenta prsevia he did not think we were doing our full duty
unless we told our patient of the danger, the high fetal mortality, and
gave her the privilege of selecting between the two methods of treat-
ment— podalic version or Csesarean section. He felt, however, that
Csesarean section had a very limited field, and that we should teach
combined version.

In discussing this paper I said that a plan of treatment suitable to all
cases cannot be selected. There are three main conditions which would
determine the course of action in any given case : The state of the
cervix ; the degree of hemorrhage ; the variety of the placenta prsevia.
When we diagnose the variety of placenta prsevia that is accompanied
by moderate hemorrhage it is not necessary to do version. The appli-
cation of the forceps and drawing the head into the pelvis will be the
appropriate treatment. If the os be not sufficiently dilated to deliver
with forceps, the membranes should be ruptured and a rubber bag ap-
plied inside the amnion, and be made to press against the placenta by
continuous extraction to control bleeding. In those cases of undiluted
cervix, with the placenta central or a large margin over the os, as soon
as the cervix has been dilated, version is the ideal treatment. Placenta
prsevia usually announces itself by a profuse hemorrhage, and the cervix,
as a rule, is found sufficiently dilated to admit two fingers. I have never
seen a case in which there had been profuse hemorrhage in which two
fingers could not be passed through the cervix. The bag of waters
should be ruptured, a large hydrostatic bag introduced and filled, and
gentle and continuous traction made upon it, to compress the placenta,
until sufficient dilatation has taken place to do version.

The cases of the central variety are the most serious from the stand
point of hemorrhage during and after labor. Here the proper thing to
do is not to waste time with tampons or rubber bags or any artificial
means to plug the cervix, but manually dilate it sufficiently to introduce
two fingers and do bipolar version, or use with care the Bossi dilator
until the cervix is opened enough to do version. In delivering after ver-
sion there is danger in too rapid delivery. The lower uterine segment is
thinned, overstretched, aud oedematous, and is readily torn, and severe
lacerations and hemorrhage can follow the ordinary speed in extracting.
In those cases in which, after version, the hemorrhage is not fully con-
trolled, gentle and steady traction on a foot will control it without injury
to the cervix. Extra precaution should be taken not to produce lacera-
tions, for frightful hemorrhages occur, either from lacerations or failure

216 OBSTETRICS.

of the lower uterine segmeni to retract. Concerning Cesarean section
for central implantation, I believe that these cases are not ideal cases for
surgical interference of any kind. Karly diagnosis and prompt surgical
treatment by Csesarean section before exsanguination is a Utopian fancy
born of inexperience.

If we recall our summons to such eases we will remember that the patient
is exsanguinated when we get to her. We do not have opportunity to
diagnose early. That fact alone excludes all but a very small propor-
tion of eases. Could we get these cases under ideal conditions Csesarean
section mighi be practicable, but we do not get them under these con-
ditions. Our present aim should be to improve maternal mortality, and
it is doubtful it Csesarean section could ever do that. I agree with
Schroeder, who said : " That man will have the best results in pla-
centa pnevia who least regards the life of the child." The conditions
inherent in placenta prsevia are against the child. 1 refer especially to
the usual prematurity of the child and its condition of apnoea follow-
ing a severe hemorrhage of the mother. Therefore, from the unfavor-
able conditions inherent for both mother and child, Csesarean section as
a means of treatment will pass away, and we will depend more and
more on version and slow extraction. Particular stress should be laid
upon the dangers of the third stage of labor — the hemorrhage follow-
ing the birth of the child. One should have at hand all the appliances
to treat this alarming condition. The insertion of a large and firm utero-
vaginal tampon from fundus to vulva is the only treatment. It should
be kept in place twenty-four hours, and gradually removed. To attempt
to stitch any lacerations is a loss of time, and will often cause the loss
of life.

Bossi's Dilator foe the Treatment of Placenta Previa.
De Paoli1 reports excellent results in nineteen cases treated by Bossi's
dilator. There were no lacerations of the cervix requiring suture, the
dilatation and extraction required from five to twenty-five minutes ; the
maternal mortality was a fraction less than 5 per cent. ; the infantile
mortality was 6.3 per cent. After dilating the cervix to 8 or 9 cm.
the child was delivered either by forceps or version. The author
declares that Bossi's dilator is far superior to Cesarean section in treat-
ing these cases. It offers the best chance to save both mother and child
in grave cases, and is indicated not only as a preliminary to immediate
delivery, but also in order to make version and slower extraction possible,
and affords less danger of infection than any other method of cervical
dilatation. The danger of serious lacerations of the cervix from too
hurried dilatation with this instrument would seem, a priori, to be espe-

1 Archiv f. Gynlikol., 1903, Bd. lxix., Heft 1.

OBSTETRIC SURGER Y. 21 7

cially great in placenta praevia, where the oedematous and soft condition
of the tissues would be prone to readily tear. The fact that this injury
did not occur in the cases reported by De Paoli speaks well for the skill
with which the instrument was used.

OBSTETRIC SURGERY.

Artificial Dilatation of the Cervix. This procedure was discussed
at a meeting of the Philadelphia Obstetrical Society, January 7, 1904,
after a paper read by Strieker Coles. The changes in the cervix
during pregnancy were first considered — its enlargement and apparent
shortening, due to its abrupt termination in the lower uterine segment.
The natural dilatation takes place at the end of the thirty-eighth week
of gestation. It is produced by the bag of waters and the contraction of the
uterine muscles pulling the cervix upward and outward. The internal
os dilates first, then the cervical canal. After increased uterine con-
tractions the external os becomes thinner and dilates. The methods of
dilatation were : 1. The introduction of the bougie, which softens the
cervix and starts uterine contractions ; the bag of waters completes the
process in from twelve to twenty-four hours. 2. When more haste in
delivery is necessary, after the bougie had been in position for eight or
ten hours, the funnel-shaped bag should be introduced ; this lessens the
time and also completely dilates the cervix and vagina. The bag used
is made of plain rubber, similar in shape to the De Ribes bag, but with-
out the curve. It is more durable, less expensive, and should be
inserted in the same manner into the uterus. 3. When great haste is
necessary in delivery, Coles prefers the hand used in the cervix after
the method of Edgar and Bonnaire, or the Bossi dilator. He believes
Edgar's and Bonnaire's method with the hand preferable to that of Harris'
because it enables one to dilate the entire cervix easier and is better applied
in a small vagina. With the hand and Bossi's dilator the cervix can be
fully dilated in from thirty to forty minutes without much laceration, but
when done in from five to ten minutes laceration will be considerable.
The use of the funnel-shaped bag had given him good results in twenty-
two cases. In one case following its removal there was prolapse of
the cord, and in another case a rise of temperature, which subsided
spontaneously. In nine cases the amniotic fluid did not remain in front
of the child's head, causing slow dilatation. The bag was introduced to
hasten delivery; four were delivered spontaneously and five with for-
ceps. In a case of twin pregnancy the bag of waters ruptured, and a
foot and the cord prolapsed when the os was the size of a half-dollar.
The foot and cord were replaced, and labor terminated successfully.

218 OBSTETRICS.

Coles' conclusions were : 1. That with the proper use of the funnel-
shaped bag, the hand, and Bossi's dilator the lives of many children
would be saved. -1. Infection would be prevented by lessening the
dangers of prolonged Labor. 3. There would be fewer lacerations of

the cervix and pelvic floor, especially when the bag was \\<v^ until the
dilatation was complete and the child was not forcibly dragged through
a partially dilated cervix and vagina.

In discussion \ stated I had always been a firm believer in dilatation
of the cervix in inducing labor for pelvic deformities of minor decree,
for kidney and other grave complications of pregnancy, and for aiding
the tedious firsl stage of labor. In the insertion of the bougies for the
induction of labor, failure results many times because the bougie is not
introduced sufficiently and properly into the uterine cavity. Fre-
quently, when called in to assist in hastening labor pains, I have found
the bougie assume a spiral shape upon removing it. It had coiled
upon itself and had not entered deeply enough into the uterus to cause
sufficient separation of the amnion and decidua. To insert properly, the
hollow bougie with a stylet having the curve of a prostatic catheter is
passed through the cervix to the point of obstruction, then the stylet
is slightly withdrawn, and at that moment the tip of the bougie is brought
toward you and closely applies itself- to the anterior uterine wall. The
stylet is further withdrawn and the bougie pushed onward to an equal
degree ; the part within the uterus is flexible, while that which has not
entered is stiff and aids in further introduction. The possible dangers
from introducing the bougie are rapture of the amnion, with prolapse of
one of the extremities or the cord, perforation of the uterus, which would
only result from carelessness or ignorance, and septic infection. In my
experience I have never known any infection whatever from this opera-
tion. The best-shaped bag I have ever used is the triangular-shaped
Voorhees bag. The baby's head is not dislocated by it, and it will
dilate like a wedge. More or less continuous traction made upon the
bag when in position will increase its efficiency. Many women tolerate
a bougie and a bag, and they fail to provoke uterine contractions. This
has been almost invariably overcome by attaching a string and a weight,
allowing traction to be continuous for two or three hours, then relieving
it, and using it again as necessary. The method of Edgar is a danger-
ous method for the general practitioner from the standpoint of infection,
because it requires a great deal of manipulation, which is bad on gen-
eral principles. In hard sclerosed cervices in multipara we are com-
pelled to use the dilators. Bossi's dilator or one of its modification is the
best devised up to the present time. The danger here is laceration, but
this depends largely upon the man using the instrument. The practical
point to bear in mind is that the rigidity of the cervix should largely

OBSTETRIC SURGERY. 219

determine the time the instrument should be used to accomplish the
desired degree of dilatation. It is not a question of minutes but of care
in the use of the instrument. I have found that uterine pains can be
hastened if the vagina is distended at the same time the Voorhees bag
is distending the cervix. In addition to placing the bougie and the
rubber bag in the cervix and arranging the traction, a Karl Braun's
colpeurynter is placed in the vagina and distended. The ordinary
Davidson rubber hand-syringe may be used for filling the bags by
wrapping the loose joints with strands of sewing cotton. The cervical
rubber bag is certainly a useful device to shorten labor in those cases
where the first stage drags along slowly for hours.

The Best Time for Repairs of Laceration of the Cervix. In the
past two years the teaching that early operation of cervical lacerations
yield the best results has gained ground. The results obtained would
seem to be sufficient to confirm us in this belief. Dickinson1 says that
there are two periods when the conditions for repair of the torn cervix
are as wrong as they can be. The first is just after delivery ; the second
months or years later. Immediately after delivery accuracy in coapta-
tion is impossible, because exact identification of the parts is out of the
question. Months or years after a cervix that is deformed, altered by
contraction, eversion, or chronic inflammation is impossible of accurate
coaptation by denudation of the surfaces of the original tear. When
neither deformity from trauma nor distortion from defective healing is
present is the desirable time to repair the cervix. No portion of the
body receives such severe traumatism and yet recovers its normal con-
dition so readily. After it has been caught between bone and bone
for hours the whole edge and inner face of the external os becomes
flayed and shaggy, and it is almost out of the question to determine
which is tear and which abrasion. Another objection to immediate
repair is that bleeding obscures the work. A third objection is that
deliberation and due care are impossible, because one is giving pain to
the patient. Anesthesia should not be used, as it favors post-partum
hemorrhage. The patient is too tired to be put on the table, a weighted
speculum is not at hand, and good work is hardly to be expected.
Sutures cannot be placed in badly contused and swollen tissues, so as
to hold satisfactorily after the swelling subsides. Dickinson's method
of repair is as follows : A Skene double tenaculum is hooked into the
circumference of the external os on each side of the tear, and the two
instruments are caught in one hand. Thus the whole injury can be
drawn to or through the vulva, and each stitch can be swung across the
two sides of the tear in a single bite. Stitches are placed one-half to

1 New York and Philadelphia Medical Journal, March 26, 1904.

220 OBSTETRICS.

three-quarter inches apart on this stretched surface. This operation, in
his judgment, need only be done to check bleeding from cervical vessels
qoI controlled by ergot, the Ik»i douche, or tampon. Whenever the
uterus is contracted Into a rigid globe, and yet active bleeding goes on,
the cervix should he sutured. 'Phis constitutes the limited field of
immediate suture. I agree heartily with his advice.

\\ hen swelling has subsided and the parts are fairly normal in con-
tour and proportion ; when ether can he given and bleeding will be
slight \ when the surfaces are yet raw and ready to unite ; when no
contractions or inflammatory processes have altered the structure, is the
desirable time to repair the cervix. This time lies between the third
and fourteenth days, more or less, after delivery. This operation is
advocated for only two classes of cases : 1. Cases of extensive lacera-
tion of the cervix running up into the body of the uterus or out to the
vaginal wall, or complete bilateral tears. 2. Cases with these or lesser
cervical injuries which have suffered perineal injury [a) running through
the sphincter ; (6) well up into the vagina ; (c) in any complicated or
deep cavity ; (rf) with very considerable oedema ; (e) in the presence
of exhaustion or shock. A perineal injury that falls in one of these
five classes should be repaired in the first or second week after labor,
together with the cervix.

After the tenth day granulation tissue makes the original injury more
difficult to outline accurately, and a curette is needed. Earlier a bit of
gauze in a forceps will clear the raw surface effectively. Chromicized
catgut has given satisfaction, though it may not do so if used immedi-
ately after labor. When the sutures are tied they should be tight and
sink slightly into the tissues, to allow for future involution. Dickinson's
conclusions are: 1. To suture cervical injuries at the close of labor
when they are the cause of post-partum hemorrhage. 2. To sew up
all cervical tears in the first week, in conjunction with the perineal
operation, when the pelvic floor injury is of such a character that a few
days' delay is desirable. 3. To repair severe injuries to the cervix from
the third to the tenth day after delivery.

The results obtained by Hirst, myself, and others conclusively demon-
strate the practicability of repair of the cervix on the fifth, sixth, or
seventh day of the puerperium. The facts that many lesser tears of the
cervix heal spontaneously, and that there are perhaps some disadvan-
tages in delaying so long the repair of injuries to the pelvic floor, as an
open wound for absorption, retraction of the fascia and muscles, the
appearance of granulation tissue, etc., have evoked some opposition to
the intermediary operation.

I believe, however, in the hands of expert operators that better results
will be obtained by delay, and that the formal operation toward the

OBSTETRIC SURGERY. 221

close of the first week of the lying-in period will become more popular
as time passes.

Dangers of Breech Presentation. J. Kucher1 believes the dangers
of breech presentation lie not so much in the presentation as in its im-
proper management. Unnecessary interference is usually at the seat of
the troubles due to this condition. If in incomplete presentations a-foot
or knee be within reach, it is a great temptation to the physician to
draw it down, hoping to hasten labor and avoid danger to the child.
Such manipulation is unnecessary and endangers more or less the child's
life. In the majority of cases there is no danger to the child until the
breech appears at the vulva. Then the cord may be pressed upon,
necessitating speedy delivery, which can easily be accomplished if the
labor has been allowed to take its normal course without interference.
When the lower extremities do not present there is no danger of too
early interference. In cases where labor lias been satisfactory up to the
last stage, followe'd by a stopping or lagging of the pains, so that for
hours no progress is made, it becomes necessary to interfere, as too long
a delay would be dangerous to both mother and child.

The author advises the blunt hook in the groin for extracting a dead
child, and has always had good success with the forceps on the living
child. It should not be applied before the breech is down in the pelvis.
A folded towel inserted between the handles of the forceps will prevent
too hard pressure of the tips of the blades upon the soft parts of the child.
Traction should be made only during a pain, and when delivering the
head it should be allowed to pass slowly through the vulva so soon as
the child's mouth is free to obtain air, thus avoiding lacerations of the
perineum.

Forceps applied to the breech is by no means free from danger.
Before engagement of the breech, if there is undue delay, the introduc-
tion of the hand to carefully flex and bring down a leg is the choice of
all methods. After engagement manual efforts will usually succeed, and
are not attended by the serious injury that may follow extraction with
the forceps in unskilled hands.

Treatment of the After-coming Head. Of the many methods for
delivery of the after-coming head, Steffeck2 believes that the methods
of Martin and Veit-Smellie are the only reliable ones. Both of these
methods, however, have the disadvantage that the infant is often so
deeply asphyxiated that it cannot be resuscitated, or is so injured that
it succumbs a few days later. While the method of Martin to some
extent avoids the danger of injury, the great likelihood of asphyxia is
not eliminated. The principle of both methods is that by artificially

1 Medical Record, July 11, 1903. ! Deutsche med. Woch., January 15, 1903.

222 OBSTETRICS.

rotating the <*liin backward and increasing the flexion of the head one
gets :i better engagement ; also with the head in this position the fingers
can be passed into the child's mouth, permitting it to breathe. Stef-
feck's experience teaches him that this manipulation in actual practice
leads to an irreparable loss of time, and that it is better not to attempt
this at all. He advises the following method : As soon as the arms
are freed, without any preliminary rotation of the chin, or flexion of the
head, or introduction of the fingers into the mouth, pressure is made
backward and downward through the abdominal wall with the doubled
fists upon the fetal head. Walcher's position assists in this manipula-
tion. When the head has fully entered the pelvis he delivers by the
Yeit-Sniellie method. He reports the use of this method with good
success for the past seven years. He has only lost one child in thirty-
six cases, and in this case both the Martin and Veit-Smellie methods
failed to deliver.

The Mechanism of Occipitoposterior Rotations. * Does the occiput
rotate forward above the spine of the ischium as the child's head
descends to the pelvic floor, or, later, when the head has descended lower
and has passed the spine ? This question was discussed by W. B. Gos-
sett.1 First, the inclined planes of the pelvis are located. The spinous
process of the ischium, situated about midway between the highest bor-
der of the great sacrosciatic notch above and the lowest margin of the
tuberosity of the ischium below, points downward, backward, and inward
toward the median line. Extending from this spine forward and up-
ward toward the upper margin of the acetabulum is an indistinct ridge
of bone. The smooth surface in front of this ridge, slanting downward
and inward, is the anterior inclined plane of the pelvis. The posterior
inclined planes are described as follows : " Draw a line on the inner
surface of the pelvic cavity from the spinous process of the ischium to
the iliopectineal eminence ; this line divides the anterior from the pos-
terior inclined plane." In the living woman this posterior plane is
completed by the muscular structure and ligaments, which fill up the
sacrosciatic foramina. Several authorities are quoted, among them Get-
chell, King, Grandiu, and Jarman, as favoring the mechanism which pro-
duces rotation after the occiput has passed below the spine of the ischium.
In contradistinction to this generally accepted belief, the author believes
the true mechanism occurs in the following manner : " In the R. O. P.
position the occiput is directed toward the right sacroiliac synchron-
drosis, the forehead toward the left acetabulum, the occipitofrontal
diameter offering in the right oblique of the pelvis." First, there is
flexion which substitutes the shorter suboccipitobregmatic diameter for

1 American Journal of Obstetrics, October, 1903.

OBSTETRIC SURGERY. 223

the occipitofrontal. The uterine contracting force is transmitted through
the fetal spine to the occiput, and thus produces greater flexion.
" The head descends, and the occiput, being the most dependent part,
meets the resistance of the pyriformis muscle and soft parts as soon as
it enters the brim. This resistance, in the majority of cases, starts the
occiput rotating away from the point of resistance to that part where
it has the least resistance, to the right and forward. This is the begin-
ning of the second step of labor in R. O. P. positions with favorable
terminations. If the resistance of the pyriformis muscle and soft parts
is not sufficient to rotate the occiput to the front, then it will pass down
behind the spine of the ischium and onto the right posterior inclined
plane, following its direction downward, backward, and inward to the
hollow of the sacrum." The author does not believe that after the
occiput once passes posteriorly to the spine of the ischium it ever
rotates forward. He sees nothing in the mechanism which could
cause it.

Tamier's Principle of Forceps Rotation in Occipitoposterior
Positions. In discussing this principle of rotation W. R. Wilson1
defines the "occipitoposterior" position as that position occupied by
the fetal head when it has passed into the cavity of the pelvis and
become fixed with the occiput directed toward either one or the other
iliac joints. This means an arrest of the progress of labor, and requires
artificial rotation, as delivery cannot usually be accomplished without it.
Theoretically the ideal application of the forceps is that with the blades
applied to the sides of the head and with the concave borders directed
toward the occiput. This latter condition permits flexion to take place
within the grasp of the instrument, and establishes a parallelism be-
tween the longitudinal axis of the head and the long axis of the blades.
In reality, there is no such symmetrical application of the forceps in
posterior occiput cases. French writers teach that it is possible while
the head is transverse to apply the forceps to the sides of the head with
one blade opposite the sacrum and the other opposite the symphysis
pubis, the coucave border of the blades looking toward the occiput.
This application gives the operator control of the head and permits him
to rotate the occiput still farther around until the latter comes under
the symphysis. But practically the oblique position of the head in the
majority of cases, where it can be overcome at all by manual deflection,
is only changed temporarily. The classic application of the blades, for
instance, in all R. O. P. positions is equally disadvantageous. The
desirable relationship between the blades and the head, in which the
concave border is directed toward the occiput, as in L. O. A. position,

1 American Journal of Obstetrics, January, 1904.

224 OBSTETRICS.

is lacking. Secondly, owing to the imperfect flexion of the head which
usually exists, the forceps grasps the -ides of the head in a vertical
direction, with the points of the blades impinging upon the submastoid
regions, thus increasing the danger to the child. Therefore it would
appear that practically the application in the transverse pelvic diameter
is the most feasible, grasping the head in one or the other oblique diam-
eters running between the frontal and parietal regions, according to the
position of the head in the pelvis. This prohibits controlling the rota-
tion of the head instrumentally while the head is high in the pelvic
cavity. If we are to carry out artificial rotation at a later stage success-
fully, the child's safety will very often depend upon the rapidity with
which it is done. When rotation is delayed through lack of flexion and
moulding, the head descends obliquely, and the wide separation of the
blades cause serious rapture of the perineum. Therefore the mother's
interests are most favorably guarded if the head can be carried out of
it- oblique position as it passes the bony outlet.

If the principles of rotation are not closely observed there will be
great damage to the mother's soft parts. Should rotation be attempted
without attention to these principles the pelvic floor would be injured
by traction upon the widely separated blades in an oblique application
to the head in an immovable position, or the vagina would be injured
by improper rotation of the blades within it. Tarnier recommends that
the handles be rotated in such a way that they describe a wide circle of
revolution, leaviug the tips of the blades as a fixed point. The pro-
cedure may be simplified by pressing the ends of the handles toward
that side of the pelvis in the direction toward which the presenting part
of the head is to rotate, without an attempt to rotate the handles. A
persistence in this lateral pressure of the handles will result in a gradual
change in their position, yielding to the direction imparted to them by
the altered position of the blades. Where such lateral pressure applied
to the ends of the handles is apparently not effective, one of three pos-
sible influences prevents rotation : 1. The attempt at rotation may be
made too early. 2. The head may be too large to undergo rotation.
3. The natural tendency may be for the occiput to rotate posteriorly or
in an opposite direction to that in which artificial rotation is attempted.

The Induction of Premature Labor for Pelvic Contraction. The
brilliant results of the elective Cesarean section in recent years have
obscured the possible value of inducing premature labor for certain
degrees of pelvic contraction. The history of a difficult forceps delivery
and the avoidance of extracting a breech in a primipara have actually
been advanced as indications for the elective Cesarean section. I have
recently reported to the Philadelphia Obstetrical Society the ultimate
results in thirty cases of induced labor for pelvic contraction (above 8

OBSTETRIC SURGERY. 225

chi. ), and wish here to emphasize the fact that a study of the statistics
of induced labor for pelvic deformity should separate the lesser from the
greater degrees of contraction, and should note the period of pregnancy
when the operation has been performed. My experience and a careful
study of available statistics have convinced me that induced labor is no
longer justifiable prior to the thirty-sixth week or for contraction below
8 cm. (3.2 cm.). With these restrictions it is an operation that will
again come into favor after the glamour of successful Cesarean sections
has faded in the light of wise conservatism.

Lorey1 endeavors to restore the reputation of induced labor by
analyzing the records of 100 cases in 82 women in the Halle Clinic ;
74 children were born alive, 14 dying within ten days, a mortality of
40 per cent. This large mortality is contrasted with the mortality of 196
children by these same women at term — 78 per cent. —showing that the
children surviving premature birth are about three times as numerous
as those who survived delivery at term in these 82 women. He com-
pares these results with those of thirteen other authors — 671 induced
labors with living children in 66.5 percent., and 802 labors at term
with living children in only 32.9 per cent. His tables show : (1) that
the mortality was 22 per cent, in conjugate vera above 8 cm. (3.2
in.); 59 per cent, in conjugate vera under 8 cm. (3.2 in.); (2) that
after induced labor operative interference markedly increases the
infantile mortality ; (3) that the best results follow induced labors
for contraction above 8 cm. (3.2 in.) at the thirty-sixth, thirty-
seventh, and thirty-eighth weeks ; (4) and that the most impor-
tant influence on the subsequent fate of the children is their feeding,
the breast-fed child having an immense advantage over those arti-
ficially nourished. These conclusions correspond exactly with my own
experience, which has been to induce labor only for contraction above 8
cm. (3.2 in.), never before the estimated thirty-sixth week, and always
to rear the child on the breast, In my thirty cases there was no mater-
nal mortality. Three of the children were lost as the result of induc-
ing labor, two from errors in calculating the period of pregnancy, and
one from prolapse of the cord ; 77 per cent, are living to-day, some of
them eight and ten years of age.

Hahl2 has also made a clinical investigation of this subject. A his-
tory is given of the operation in Denmark, Norway, Sweden, and Fin-
land, with an analysis of 84 cases so treated in Helsingfors. His cases
show a large proportion of associated complications, operative deliveries,
and degrees of contraction, sometimes too great to permit the lowest
infantile mortality following induced labor. As I have stated above, this

1 Archiv f. Gynakol., 1904, Bd. lxxi., Heft 2. ■ Ibid., 190:!, Band lxxi., Heft 3.

15

226 OBSTETRICS.

operation should not be attempted in oases now generally included in
the range <>f elective Csesarean section, which rightly has excluded from
induced labor conjugates below 8 cm. (3.2 in.). Hahl's1 84 cases were
taken from 23,000 labors, being a ratio of 1 to 274. (Compare Leopold
1 in 131, Braun Fernwald 1 in 441,Chrobak 1 in 627, A. Pinard 1 in
L50.) The 8 I operations were performed upon 47 women (13 twice, 6
once, I four times). Only one patient was a primipara. The ages
varied from twenty-one to forty-three years. A moderate pelvic con-
traction was the indication, and the earliest period at which it was done
was the thirtieth week, the latest the thirty-eighth week ; the average
was between the thirty-fifth and the thirty-sixth week. Seven presen-
tation- were transverse and fourteen breech. The complications were
placenta prsevia (1), rupture of the uterus (1), prolapse of the cord (3).
In 25 eases labor ended spontaneously, the remainder, 59, were termi-
nated artificially by forceps or version (perforation twice). The mater-
nal mortality was 2, or 2.38 per cent., 1 from puerperal fever
and 1 a sudden death, the cause of which could not be determined.
The puerperium was febrile in 6 cases, or 7.23 per cent. ; 63 chil-
dren were born alive, 75 per cent. ; 8 of these died within the first
twenty-four hours of life, and 5 within the first two weeks; 50 chil-
dren, 59 per cent., survived over a year. The writer compares these
results with those of many authorities, among whom John Moir2 records
the most favorable results; 80.8 per cent, of his 73 cases were suc-
cessful as regards the life of the child. Various methods have been
used in Helsingfors, but all have been abandoned, except the four now
used and recommended. The bougie was used in 25 cases, but since
L891 has beeu superseded by the " catheter with condom." Tarnier's
intrauterine dilator was employed, either alone or with other methods,
in 22 cases. Champetier de Ribes' bag has been found invaluable.
The results of induction of premature labor have steadily improved
during the past thirty years, and the author believes the operation
still has a valuable place in obstetrics.

Dirner3 summarizes 55 cases of induced premature labor which have
been reported up to the present time in Hungary. The first was
performed by Semmelweiss in 1856 ; 14 of the operations were per-
formed by the author himself. The indications were kidney disease,
heart affections, phthisis, but in most instances narrowness of the
pelvis. He considers that from the thirty-fourth to the thirty-eighth
week is the best time for induction labor, and that the best method was

1 Journal of Obstetrics and Gynecology, British Empire, March, 1904.

2 Scottish Medical and Surgical Journal, 1898, vol. xi., No. 6.

3 Szuleszet i\s N6gy6gyasz&t, 1903, No. 3; Journal of Obstetrics and Gynecology,
British Empire, September, 1903,

OBSTETRIC SURGERY. 227

metreurysis with the Barnes-Fehling colpeurynter, after previously
dilating the cervix with Hegar's dilators. He also believes in the
Krause method. The fetal mortality in his own cases was 35.7 per
cent.; but omitting two cases of eclampsia it would be 17 per cent.

Version in Contracted Pelves. In an analysis of a series of 320
cases of contracted pelves, Krull1 has drawn the following conclu-
sions : 1. Version and extraction may be successful both as regards
mother and child, in simple flattened and flattened rickety pelves if the
child is of average size ; also in generally contracted flattened rickety
pelves if the diagonal conjugate is not less than U cm. (three aud three-
fifth inches), and in generally contracted pelves if the diagonal conju-
gate is uot less than 9J cm. (three and four-fifths inches). 2. Version
should be avoided, if possible, iu primipara. Expectant treatment is
always indicated here. 3. Expectant treatment may also be tried in
multipara if there is a favorable vertex presentation. Version often
gives good results, and may avert Cesarean section or symphyseotomy.

The aim of inducing labor for cases that may be successfully delivered
at term by version or forceps is to secure a softer aud smaller head
in order that nature may spontaneously deliver the patient ; and an
operative delivery, more dangerous because of the prematurity of the
child, should therefore be deferred to the last possible moment. The
combined Trendelenburg- Walcher posture will often assist the delivery
and make operative interference unnecessary, and thus further reduce
the infant mortality following induced labor.

Symphyseotomy. The results of the elective Ca^sarean section in
recent years have been so satisfactory that the indications for symphyse-
otomy, at one time promising a rather wide range of usefulness, have
come to be more and more restricted. Reports of cases in the world's
literature have disappeared with almost as amazing rapidity as formerly
successful cases were recorded. That symphyseotomy continues to have
a place in modern obstetric surgery, I think there is no doubt, but only
under exceptional circumstances will it be the operation of choice.

In discussing this operative procedure, V. Cocq2 cites the chief indi-
cations for its use as the probability of previous infection of the uterine
cavity by repeated ineffectual forceps applications and an inability to
obtain suitable assistance to perform Osesarean section. For the physi-
cian unskilled in surgery or in unsuitable surroundings, embryotomy is
the only resource in case of the death of the child or a desperate con-
dition of the woman. The author considers symphyseotomy as occupy-
ing an intermediate position between Cesarean section and embryotomy.

1 Archiv f. tiyii., Bd. lxvii., Heft 2.

! Bulletin <le la Soc. Beige <le Gyn. et d'Obstet., t xiv. No. 1.

228 OBSTETRICS.

It would be used most frequently in pelves with ;i true conjugate of
7 cm. to 9 cm. <V"_M to :'» ; in.). Forceps should first be tried in pelves
with a tnii> conjugate over 8 cm. (3.2 em.). Symphyseotomy should not
be employed in conjunction with the induction of premature labor or
embryotomy in pelves whose true conjugate measures from 5 cm. to
7 cm. (2 to 24 in.).

Pubiotomy by Gigli's Method.1 This operation has been reviewed
by Baumm.2 It was first described by Van de Yelde in 1902, and soon
thereafter by Gigli. These writers make it appear that pubiotomy is
destined to take the place of symphyseotomy in obstetrics. Symphyse-
otomy is easier of performance than Cesarean section and valuable in
the interests of the child. In addition, such accidents as tears of the
vagina, bladder, urethra, and corpora cavernosa of the clitoris can be
overcome by a blunt dissection of these structures from their bony attach-
ments before dividing the cartilage, although incontinence of urine may
follow symphyseotomy however carefully it may be performed. Gigli
says that all these objections can be overcome by dividing the pubic
bone to one side of the symphysis outside the joint and attachments of
the soft structures. Gigli also claims that one should get better union
after pubiotomy than symphyseotomy. Baumm considered the opera-
tion worthy of trial, and operated upon two cases on following days.
These cases were considered ideal for symphyseotomy. The incision
was made to the left of the median line. In dividing the muscle down
to the bone there was considerable hemorrhage, which could only be
controlled by tampons. The bones were exposed by blunt dissection.
Gigli's wire saw was then passed around and the pubic boue severed ;
the ends at once separated about two inches. Both children were de-
livered alive by forceps. In both cases the vagina tore through into
the wound, and in the second the bladder was also torn. Therefore
the chief claim made for this operation failed in both instances. The
wound was as great, the walls as torn and bruised as they usually are
in symphyseotomy, and, in addition, there were the cut ends of the
bones in the wound. This gave a very bad wound for prognosis and a
most difficult situation in which to maintain asepsis, because of the
exposed ends of the bones and the communications with bladder and
vagina. One case had a severe postpartum hemorrhage and was very
ansemic. Both cases died from sepsis. The author concluded he has no
desire to test the operation farther. The performance of the operation
presents no great difficulty, and it has no advantages over symphyseotomy.

Embryotomy in Transverse Dystocia. In impacted transverse
positions, the child having perished, when the neck can be reached

1 Journal of Obstetrics and Gynecology, British Empire, August, 1903,
'■'■ Monats. f. Geburts. und Gynak., Bd. xvii., Heft 5,

OBSTETRIC SURGERY. 229

easilv, decapitation is without doubt the operation of choice. When
the neck cannot be reached, and an impending uterine rupture pre-
vents any forcible handling, L. E. Hering1 uses the following tech-
nique : The instruments required are several bullet or museau for-
ceps, a volsella forceps, and a pair of strong, straight episiotomy
scissors. The thorax of the child, as it presents, is grasped by two
forceps placed side by side ; should an arm present to interfere with
the operation, it is at once amputated, as it is not of any use for trac-
tion in the procedure. The thorax is opened in one of the intercostal
spaces bv cutting between the forceps with the scissors. The forceps
are then reapplied so as to include the whole of the thickness of the
thoracic edges. This opening is enlarged and the heart and bloodvessels
grasped in the volsella forceps and twisted off. While an assistant now
makes traction downward and separates the forceps the operator enlarges
the transverse incision toward the spine by cutting and reapplying the
forceps until the spinal column is reached ; this is then cut through
with the scissors. Traction is then applied to the body, and it is
brought down so that any further manipulations can be performed in
the vagina. By the same means of reapplying the forceps and cutting,
repeatedly done, the Avhole body is cut through. The lower half of
the foetus is then reposited ; the upper half is first extracted by volsella
forceps, then the lower. Some strength and care are required in cutting
through the spinal column. Ordinary care should prevent cutting by
any of the sharp edges ; the whole operation can be done in half an
hour. Some of the advantages claimed for this operation are : 1. That
the total transverse separation of the fetal thorax can be applied
whether the shoulders occupy a high or low position. 2. It is not
necessary to introduce the hand into the cervix, and it also removes all
danger of uterine rupture by lessening the volume of uterine contents.
3. It can be done with much less intrauterine manipulation than ver-
sion and extraction when rupture is threatened. 4. There is no remain-
ing head to be delivered, as in decapitation, and, owing to the exhausted
condition of patients, anaesthesia can be dispensed with, thereby elimi-
nating some risk.

Vaginal Csesarean Section. This operation, frequently called
Diihrssen's operation, has been gaining adherents recently, following
the enthusiastic claims of Duhrssen and others. As a rapid method
of extracting the child, under certain circumstances it offers the expert
vaginal operator a very efficient means of quick delivery. Diihrssen
has advanced the following indications : 1 . Obstruction of the cervix
and lower uterine segments due to cancer, stenosis, myoma, or extreme

1 Medicine, November, 190?>.

230 OBSTETRICS.

rigidity, which prevent cervical dilatation in the presence of pains.
2. Dangerous conditions of the mother, as grave cardiac, renal, or pul-
monary diseases, which may be relieved by prompt emptying of the
iitern-. 3. Diseases which may become fatal before the child is born,

as placenta pnevia or eclampsia, in which treatment has been of no avail.
When the pelvis is contracted the conjugate should be at least 8 cm.
(3.2 in.) to permit the selection of this operation. The technique of the
operation consists in cutting through the anterior fornix and rapidly
separating the bladder from the nterns ; then the anterior wall of the
cervix and lower uterine segment is incised. For full-term delivery
the posterior fornix is also opened, the peritoneum in Douglas' cul-de-sac
separated, and the posterior wall of the cervix and lower segment incised
similar to that of the anterior wall. The foetus is rapidly extracted,
usually by podalic version, the placenta removed, the uterine incisions
are closed by sutures, and the uterine cavity is tamponed.

Diihrssen1 insists that this operation must not be classed with accouche-
ment force", since dilatation in the latter is inadequate and may be fol-
lowed by fatal rupture aud tearing of the uterus at the moment of
extraction. This accident can never happen after the proper incisions
in the vagina, cervix, and possibly the lower uterine segment, as carried
out in vaginal Caesarean section. He claims that the operation should
never prove fatal, and that it will come to be recognized as a procedure
indorsed by all obstetricians. He classifies vaginal Caesarean section as
(a) radical, and (b) conservative. The radical operation consists in
longitudinal incisions through the cervix and, if necessary, the lower
uterine segment, and after delivery an hysterectomy is performed, as for
pregnancy complicated with carcinoma of the cervix. The conservative
operation concerns only emptying of the uterus, as described in the fol-
lowing case : The patient, aged thirty years, a V-para, had uncontrol-
lable hemorrhage in the second month of her sixth pregnancy. Ante-
rior hysterectomy was performed in the fifth month. The portio wras
fixed with two side ligatures, and a longitudinal incision was made
through the anterior vaginal wall and cervix. The bladder did not
come into view and did not require separation from the uterus. Two
fingers passed into the wound delivered a 20-cm. (8-in.) foetus and a
placenta prsevia. Sharp hemorrhage following, the uterine cavity was
packed with gauze. The cervix was sutured with interrupted catgut
stitches and the vaginal wall with continuous catgut, leaving a small
space for gauze drainage. The vagina was then packed with gauze.

The operation has been performed about one hundred times, and is
not more dangerous than other obstetric operations. According to the

1 Zentralbl. f. Gynakol., 1904, No. 13.

OBSTETRIC SURGERY. 231

author, its special field is for grave cases of eclampsia with a rigid cervix.
A narrow vagina may require preliminary perineal incision.

J. M. Munro Kerr1 reports four cases in which this was the opera-
tion of choice. He considers that the greatest argument in favor of this
procedure is that it is sometimes the only method by which rapid
emptying of the uterus is possible — i. e., in a case where the cervix is
so rigid it will not stretch, or where there is uncontrollable vomiting
and the cervix cannot be dilated, as reported by Ehrendorfer.2 A
saving of time is another advantage, for this operation can be done in
four or five minutes. Only occasionally is time of great importance,
as the difference between emptying the uterus in five minutes by this
procedure and thirty minutes by Bossi's dilator is immaterial. Still
there are cases where one or both lives may be saved by the more rapid
method. A third advantage claimed is absence of shock, though the
author does not attach much importance to this. He has seen shock
produced by it, though not alarming. The last advantage claimed is
that the operation is more surgical and gives one a clean cut wound to
deal with. While this claim proves nothing, most of us prefer to deal
with an incised rather than a lacerated wound ; hence if we knew that
a cervix would be lacerated by the use of Bossi's dilator we would
prefer incision. There are cases where one may expect lacerations,
and therefore incisions would be preferred to dilatation. In cases of
pregnancy of seven months or under, and, in cases of great rigidity in
the later months, lacerations are to be expected, and incisions therefore
are preferable. The most adverse criticism has come from those who
have neither seen nor performed the operation, which is not, as is
thought by many, of considerable magnitude and difficulty. The
bladder can be separated from the gravid uterus easily, and scissors
should be employed to make the incisions, which are thus not difficult.
The stitching is the most difficult part, and requires good light and
assistance. The edges should be grasped firmly in volsellum forceps
and drawn downward while the stitches are introduced.

The dragging on the uterus completely controls any hemorrhage.
One must, however, admit it is not an operation for ordinary general
practice. There, Bossi's dilator, if it can at all with safety be used,
should be employed. The objection that difficulty in subsequent labors
may be expected cannot yet be verified by experience, and one would
rather think that such would not be the case. The author considers
it a little difficult and, perhaps, not wise to predict the place this operation
will occupy in the future ; but that it has come to stay he feels certain.

1 Journal of Obstetrics and Gynecology, British Empire, March, 1904.

2 Zentralbl. f. Gyniik., April 18, 1903.

232 OBSTETRICS.

It will usually be the operation of choice in cases where the cervix is
too rigid to dilate and where the uterus must be emptied at once, in
cases where the saving of time is important, and where there is danger
of laceration by the use of metal dilators. He thinks, perhaps, it will
have a great place in accidental hemorrhage, in which so many recom-
mend hysterectomy. In eclampsia, he believes, it should displace
ordinary Cesarean section in those rare cases of rigid and unobliter-
ated cervix, in most of which cases, however, 1 believe, Bossi's dilator
will be efficient and sufficiently rapid.

The ill effects that may follow the incisions of vagiual Cesarean
section must not be forgotten, for they would appear as likely as after
the incisions of the cervix, recommended loug ago by Pi'ihrssen for
rapid delivery in place of the manual or instrumental dilatation in
accouchement ford. Hoffmeir1 records two cases in which serious con-
sequences followed these incisions, made at previous labors. In one
case the cervix failed to dilate, and finally required sounds, the fingers
and Frommer's dilator in turn. The child was dead, and craniotomy
was done. The second case died from an incomplete rupture of the
uterus through the scar of one of the old incisions, although the patient
had had two normal confinements after the one in which the cervix
had been incised. He believes that these incisions are not as free from
danger as Diihrssen claims, and refers to the lateral incisions as espe-
cially dangerous and more likely to produce serious hemorrhage by
dividing large vessels. In cases where incisions must be made, ante-
rior and posterior incisions of the cervix are the least dangerous.

The Mechanism and Treatment of Rupture of the Uterus. Iu
rupture of the uterus it is by no means necessary that the laceration
should occur from without inward, or vice versa. It may primarily
originate in the musculosa and extend either outward or inward, or in
both directions, according to Knauer.2 A woman was admitted to the
hospital with symptoms of impending rupture, and was delivered by
craniotomy. The lower uterine segment was thinned to barely 2 mm.,
but the internal surface was intact. By the left side of the uterus in
front and extending into the broad ligament there was a hseniatoina
larger than a man's fist. A. laparotomy was done the fifth day after
labor on account of symptoms of peritonitis. The peritoneum uear the
symphysis over the hrernatorna was torn, but there was no communica-
tion with the uterus. The patient died from peritonitis. The autopsy
revealed a primary isolated laceration of the musculosa of the lower
segment without any injury to the internal decidual surface or serosa.

1 Miinchener med. Woch., 1904, No. 3.

2 Monats. f. Geb. u. Gyn., B. xvii., S. 1279; British Gyn. Journal, February, 1904.

OBSTETRIC S UR GER Y. 233

The tear in the peritoneum was transverse, and was secondarily due to
the extreme distention by the hematoma. The rupture was probably
due to a mass of caseous tuberculous glands which had prevented the
engagement of the head. He also gives three cases of ' ' incomplete
external rupture," the worst form of spontaneous rupture of the uterus
in labor.

Case I. Post-mortem. There was extreme general anaemia from
hemorrhage into the peritoneal cavity from numerous longitudinal tears
a few millimetres to several centimetres in length. The longest tear was
5J cm., and gaped to the extent of 12 mm. in the perimetrium and
musculosa, the others affected only the perimetrium.

( Jase II. Post-mortem. On the posterior surface of the uterus there
were numerous tears in the serosa, many 1 to 2 mm. and a few 2 cm.
long. The larger ones exposed the musculosa suffused with blood.

Case III. Post-mortem. The uterus was much enlarged, and re-
vealed on its posterior surface two parallel superficial lacerations, 4.5
cm. and 5 cm. long, both gaping. The musculosa beneath them was
free from hemorrhage. In all these cases there was premature detach-
ment of the placenta, and Knauer believes there must be some etiolog-
ical connection ; most likely the extreme distention of the uterus by
hemorrhage into its cavity caused the laceration of the perimetrium.
He says that whenever we know the uterus to have undergone a sudden
and extreme distention, with symptoms of anaemia without signs of
external bleeding, we should suspect laceration of the peritoneal cover-
ing of the womb and internal hemorrhage.

Dorland1 states that the rupture may occur anywhere iu the uterine
wall from the fundus to the internal os ; it may be limited to the cer-
vical tissues, or extend outward from the neck into the vaginal vaults
and pelvic connective tissue ; it may occur in the vaginal wall with or
without the development of a pelvic hematoma, or it may take place
in the perineal tissues during the delivery of the head through the
vulvar ring. He reports a case, and gives a critical review of 50 cases
from the standpoint of treatment. His patient was a negress aged
thirty years. She had been in labor three and one-half days when
admitted to the hospital. One and one-half years before she gave
birth to a child after a labor of four days. The labor had been slow,
pains ineffective, and voluntary forces inactive. Examination re-
vealed the foetus in R. O. P. position, with an arm overlapping the
vertex and a loop of cord prolapsed. It was decided to turn the child
and deliver by the feet. The body was delivered without difficulty,
when suddenly the cervix contracted about the fetal neck. Traction

1 Medicine, June, 1904.

234 OBSTETRICS.

by the Wiegand method was ineffective, also an attempt to use forceps.
\\\ using greater force the child was manually extracted stillborn.
Profuse hemorrhage immediately followed, and digital examination
revealed a tear in the lower uterine segment posteriorly and to the
left ; the lingers passed into the peritoneal cavity. The placenta was
quickly removed and a gauze tamponade introduced while preparing her
for abdominal section. On opening the abdomen a rupture two and one-
half inches long, extending lengthwise upon the left side, was found.
The tear was sutured with silk, clots removed, and the abdominal
wound closed. Three days after operation a slough began to form at
the uteriue surface of the tear, followed by a foul-smelling discharge
and irregular chills. The temperature reached 104.8° F. on the ninth
day, when it suddenly dropped. The patient made a good recovery
after this time.

There is a large class of abdominal surgeons and obstetricians who
prefer the expectant treatment to immediate surgical intervention.
Schmit,1 who reports 19 cases of uterine rupture, is an exponent of
the expectant plan ; 7 of 9 cases of incomplete rupture were treated
by drainage, 1 case received no special treatment, as the rupture was
not clinically recognizable, and 1 case died from hemorrhage before a
laparotomy could be undertaken. Of the 7 cases treated by drainage
2 died ; a mortality of 28.57 per cent. There were 10 cases of com-
plete rupture — 4 treated by operation, 6 by drainage. The mortality
was 50 per cent, in both methods of treatment. Altogether, the
mortality of the operative method Schmit gives as 50 per cent., while
in those treated by drainage it was but 38.4 per cent.

Schmit then gives the results from a critical study of 179 cases
treated in various clinics. He proves that drainage gave far better
results than operative treatment. The expectant treatment gave 51.8
per cent, of recoveries. The operative treatment gave only 25 per
cent, of recoveries. His conclusion is that, except in those cases in
which severe hemorrhage or lacerations make operative treatment im-
perative, better results will be obtained by a conservative plan. Klein,
of Dresden, quoted by Smyley,2 found from a careful analysis of 381
cases that the results of the two plans of treatment were almost the
same, the mortality after operation being 44 per cent., after packing
and drainage 39 per cent. Mann, of Buffalo, declares statistics show
the best results following operation contrasted with drainage. Var-
nier's statistics show the mortality after packing and drainage is very
high, while operation is more successful. Franque advises the prac-

1 Monats. f. Geb. u. Gyn., September, 1900.

2 Lancet, April 27, 1901.

OBSTETRIC S UR GER Y. 235

titioner, when rupture occurs in private practice, to deliver through
the vagina if possible, then apply a pad and bandage to the abdomen,
and insert a drainage tube or a strand of iodoform gauze into the
uterus. Wiener1 prefers operation to tamponing the uterus. Kolo-
menkin2 thinks couservative treatment by packing and drainage is
inadequate ; complete and incomplete ruptures have the same daugers,
and should be treated similarly. Traumatism, and especially that asso-
ciated with an attempt at version, is stated as the most common excit-
ing cause, while scars at any point in the sphere of the genitalia, due to
previous labors or operations, are predisposing factors. From 1901 to
1903 there have been 50 cases of uterine rupture reported in litera-
ture ; 12 of these cases died, a mortality of 24 per cent. ; 3 died of
hemorrhage or shock before any treatment could be instituted ; 16
were treated expectantly by gauze packing and drainage, and 4 per-
ished, a mortality of 25 per cent., which is greater than the total mor-
tality of the 50 cases ; 31 cases were treated by operation, and 5 of
these died, a mortality of 16g4T per cent. The superiority of the
operative method is here evident. Of 9 cases of complete laceration
of the uterine wall treated by tampon and drainage 4, or 44.4 per
cent., died. Compare this with 30 cases of complete rupture with 5
deaths, a mortality of 16 f per cent. The writer draws the following
conclusions : Incomplete lacerations of the uterine wall, with moderate
hemorrhage and an accurate diagnosis, may be well treated by vaginal
and intrauterine tampons and an expectant course of treatment. Com-
plete lacerations into the peritoneal cavity in unclean surroundings
should be temporarily treated by intrauterine tampons, administration
of astringents and stimulants until the patient can be conveyed to a
hospital and operated upon. Under favorable circumstances the cavity
should be opened as soon as possible, and the rupture of the uterine
wall sutured in suitable cases, or a Porro operation or a total extirpa-
tion be performed, as is necessary.

Labusquiere3 presents a paper upon this subject, based upon the
experience of different authorities since the establishment of antiseptic
obstetrics. He believes that, altogether, operative treatment offers the
best chance of recovery, while expectant treatment involves the most
peril. Several operative procedures are discussed, and among them
Zweifel's method for applying sutures through the serous coat alone,
thereby converting a total into an incomplete rupture. In this opera-
tion care must be taken not to elevate the pelvis and distribute the
blood and lochia through the peritoneal cavity. The blood and lochia

1 American Medicine, December 27, 1902.

2 Monats. f. Geb. u. Gyn., 1903. • Ann. de Gyn. et d'Obst<?t., July, 1903.

'

236 OBSTETRICS.

are tir-^t removed, all surfaces being rendered scrupulously dry and
• ■lean. The sutures arc then applied through the serous coat on each
side of the lacerations and tied. This "exclusive suture" method
was first practised in a case so collapsed that panhysterectomy was
inadvisable. It is in those cases in which major surgery is out of the
question, owing to the condition and surroundings of the patient, that
this operation has its field. Labusquiere cites the successful report of
Pajot's method of packing the uterus and draining several years ago,
and compares it with Yarnier's statistics, in which simple packing and
drainage yielded a high mortality ; the results of operative procedure
were much better. He believes it is bad surgery, as a rule, to perform
a complete suture of the muscular coat of the uterus, though attempts
have been successful. The edges of the wound have in all probability
become septic before the operation can take place, and therefore only
those small tears where one can be practically certain of a clean wound
should be so treated. Franque advises the practitioner, when a rup-
ture of the uterus occurs, to deliver by the vagina if possible, apply a
pad and bandage over the abdomen, and a drainage tube or strip of
gauze into the uterus. Klein advises packing and drainage. Kolo-
meukin1 reports five cases, all of which recovered after operative pro-
cedures. In three cases an abdominal hysterectomy was done, in one
a vaginal hysterectomy, and one a Porro. From his experience and a
careful study of statistics he believes that operation yields better results
than conservative treatment, and that there is no essential difference, as
far as treatment is concerned, between a complete or partial rupture.
In exceptional cases only may conservative treatment be undertaken.
Operation should be performed as soon as possible, and the best results
are obtained by total extirpation of the uterus with drainage into the
vagina.

Rupture into the Parametrium. A unique case of laceration of
the parametrium and disappearance into the rent of a four months'
fetal head is reported by Weber.2 A physician treating a case of
abortion at the fourth month attempted to empty the uterus. Traction
on the legs of the foetus detached the head, which would not pass the
undilated cervix. The hand was passed into the uterus and an
attempt made to hook a finger over the head, and thus extract it. The
head suddenly disappeared and a laceration of the cervix could be felt,
through which the head had apparently escaped. Coeliotomy was per-
formed. The peritoneal covering of the uterus and broad ligaments«was
intact, but a swelling was found between the layers of the upper part of

1 Monats. f. Geb. u. Gyn., vol. xvii. Sec. 4.

2 Zentralblatt. f. Gyn., February 13, 1903.

OBSTETRIC SURGERY. 237

the right broad ligament, which was incised and the head extracted. There
had been no hemorrhage into the parametrium. The peritoneal incision
was closed with catgut suture. The patient recovered without incident.

The case is analogous to one reported by Orthmann. In his case,
as a result of criminal abortion, the placenta and membranes were
forced through a laceration into the right parametrium. Efforts to
extract them per vaginam through the laceration failed, as did an
attempt to express them through the rent after opening the abdomen.
A peritoneal incision was required through the broad ligament.

The Effect of Pregnancy on the Cicatrices of Previous Opera-
tions upon the Uterus. That the various operations practised upon
the uterus which necessitated incisions into its substance are not to be
thoughtlessly undertaken is well demonstrate by a case reported by
v. Fallenberg.1 The uterine end of one tube was excised by a wedge-
shaped incision and the wound was sutured. The subsequent preg-
nancy resulted in a rupture of the uterus at the site of the scar causing
the death of the patient. In this case the implantation of the ovum was
in the neighborhood of the scar. All wounds in the uterus should be
most carefully sutured by uniting the various layers, if necessary, in
order to prevent subsequent rupture in labor. This is further most
markedly emphasized by the case recently observed by Herman- of a
dwarf upon whom two years previously he had done a Cesarean sec-
tion. She again became pregnant, and when at full term abdominal
palpation revealed the presence of the fetal head lying just beneath
the skin, and upon this finding Herman diagnosed a rupture of the
uterus with extrusion of the child into the abdominal cavity. A
laparotomy was at once performed, and it was found that the cica-
trix in the uterine wall had given way and the gestation sac was
partly within and partly without the uterine cavity. Its anterior
wall was formed by the omentum above, the abdominal wall in
front, and the utero vesical cul-de-sac below. The placenta was
found on the posterior wall of the fundus. On extraction of the
placenta the amniotic sac followed it out, detaching itself from within
outward as far as the edges of the abdominal wound. It was remarked
that the edges of the uterine rent were thick and rounded and did not
bleed, and that there was no blood in the amniotic sac. In other
words, the extrusion had been gradual.

Spontaneous Amputation of the Cervix in Labor. Spontaneous
amputation of the cervix during the progress of labor is a very rare
condition. It has been noted twice in the past six years by Merkulieff.3

I Archiv f. Gyn., Bd. lxxi. S. 300. Semaine M.'.l., 1904, No. '.).

II .lour. Akous. i. (Hens., Boliesnev, April, 1903,

238 OBSTETRICS.

One case was a primipara aged twenty-seven years. The labor had been
tedious. Lasting about thirty-six hours, at the end of which time the
cervix was cast off through the vagina. Only a very slight hemorrhage
accompanied the separation. The child was delivered by forceps, and
the mother made a good recovery. Previous to the separation of the
cervix she had had weak, ineffectual pains, with a swollen, edematous
conditioD of the cervix. The second case was a multipara aged twenty-
six years. Twenty hours after labor began the cervix separated and
came away. The child was delivered by forceps, and the patient made
a good recovery. In the first case there was an absolute narrowing of
the pelvis, and in the second a relative narrowing, due to a large head.
Therefore the author believes a narrow pelvis to be one of the predis-
posing causes of this accident. Another possible cause he mentions as
irregularity in the mechanism of dilatation, thereby causing pressure
upon one point of the cervix during uterine contractions. In these
eases microscopic examination of the tissues showed no special changes
favoring separation. If it is detected in time an incision in the cervix,
followed by forceps delivery, may prevent this accident, but this is
rarely possible.

The Relation of Placenta Praevia to Subsequent Pregnancy.
Radtke1 has studied the condition of eighty patients following placenta
praevia ; 30 per cent, remained sterile, and about the same percentage
aborted in the subsequent pregnancy, due to various pathological con-
ditions, especially endometritis and lacerations of the cervix. From his
studies he concludes that in very many cases marked injury to health
results from placenta praevia, and that it is the duty of the physician
to carefully examine and treat any pelvic disorders within a reasonable
time after delivery to prevent serious and chronic pelvic disorders.

Obstetric Analgesia. Von SteinbucheP states that the ideal nar-
cotic for obstetric patients should (1) allay pain without diminishing the
force of the uterine contractions ; (2) should not be dangerous ; (3) the
dangers of inhalation narcosis, if that be necessary, should not thereby
be increased ; (4) the life of the foetus should not be endangered, and (5)
post-partum hemorrhage or uterine inertia should not be favored or
produced. He recommends, as meeting these requirements, a combina-
tion of scopolamine (0.0003 gram [Y^ gr.]) and morphine (0.01 gram
[I gr.]), and declares that by this treatment the pain and suffering
of labor is much lessened without affecting consciousness or uterine
activity. Green3 tested this method in the Boston Lying-in Hospital
in 1!» cases, and from his observations concludes that in scopolamine-

1 Zentralblatt f. Gymikologie, November 19, 1903.

•-' Ibid., November 29, 1902. 3 Medical News, October 10, 1903.

MANAGEMENT OF THE THIRD STAGE OF LABOR. 239

morphine narcosis we have a valuable addition to obstetric thera-
peutics ; that while in a few cases of multipara (3) there was no
apparent benefit, the good effects in 16" primipara were very marked.
The combined use of the drugs was especially serviceable in primipara
of nervous, excitable, and hyperasthetic organization ; and the best
results are obtained when the drugs are given early in the first stage,
as soon as symptoms of nervous irritability manifest themselves,
Scopolamine hydrobromate and morphine uitrate were so combined
that ten minims of the mixture contained ^1^ grain of the former and
,'. grain of the latter drug ; it was administered by subcutaneous injec-
tion, the dose being repeated in a few cases once or even twice at two
or more hour intervals, according to its effects. Therapeutic investi-
gations have, I believe, demonstrated that scopolamine and hyoscine
are practically identical, and explain Green's observation that the use-
fulness of the drug is confined to nervous and excitable patients, and
especially primigravidse, whose nervous excitability during labor is
generally more marked than in multipara?.

MANAGEMENT OF THE THIRD STAGE OF LABOR.

Dangers of Crede's Method of Expression of Placenta. While
Crede's method has undoubtedly been of great benefit in many cases of
labor, it is well to remember the dangers in connection with its use.
The British Medical Journal, August 15, 1003, in noting the danger of
perforation by pushing a finger through the wall of a thin uterus, dis-
cusses a case reported by Dr. Schwendener at a German medical society.
It is of importance from its medico-legal aspect, as a similar mishap
under different circumstances might get a practitioner into trouble.
The specimen was exhibited as illustrating rupture caused by expres-
sion of the placenta. The patient was thirty-two years of age, the
mother of eleven children. The child was born spontaneously. The
placenta remained for an hour when firm expression was practised,
manual extraction became necessary, and proved exceedingly difficult.
Symptoms of rupture of the uterus developed immediately after its
removal, and the patient died soon afterward. The uterine wall re-
vealed a small, ragged hole, about the si/e of a five-cent piece. Around
the hole an ingrowth of decidual tissue into the muscular wall was
discovered. Dr. Asch suggested the interpretation that in multipara
the uterine wall is occasionally very thin in places, almost transparent.
This condition is aggravated by the dilatation of venous sinuses, and a
hematoma may lie in the wall under the spot where the placenta
adheres. This hematoma might easily be burst by firm pressure
during Credo's manoeuvre, which would produce a hole in an abnor-

240 OBSTETRICS.

inally thin uterine wall. While doubt was expressed that the uterine
wall could be so perforated by the obstetrician's finger pushing the
abdominal parietes before it, and the possibility stated that at some
previous labor the uterine wall may have been injured at this site,
nevertheless it seems clear that, directly or indirectly, the uterine wall
may be perforated by the linger in expressing the placenta, which is a
practical point every obstetrician should bear in mind.

A New Method of Expressing the Placenta. A new method has
been devised by Budberg-Benninghausen1 for the expression of the
placenta in the third stage of labor. He believes the Crede method is
not based upon a rational anatomical and physiological basis. After the
second stage of labor the uterus enters into a state of physiological
rest ; if this rest be disturbed, atonic post-partum hemorrhages will
result. The author's method, first described in 1898, is based on
principles directly opposed to those underlying Crede's method. He
believes the uterus should not be pressed downward, but should be
fixed in place during the expulsion of the placenta. He advises
1 • that the fingers of one hand be passed over the fundus posteriorly,
the thumb pressing on the anterior surface. The other hand lies over
the anterior surface of the uterus parallel to the pubis, the thumb and
palm of the hand pressing on one side while the fingers press upon
the other." Pressure is made with the uterine contractions, the womb
being fixed so that the placenta can escape when the contractions take
place. The pressure should increase and diminish with the strength of
the contractions, decreasing gradually, not remitting suddenly, as is
often done in Crede's method. Should the contractions be weak and
inefficient the uterus may be stimulated by grasping it tightly in the
hands, but in no case should the hand grasping it be entirely relaxed
until the placenta is expelled. Should the abdominal walls be too
thick to permit of grasping the uterus conveniently, the left hand
should be inserted in the vagina, the two longest fingers inserted into
the fornices, and the uterus thus pushed up, while the right hand com-
presses it, as described. The author declares this method efficient,
having used it in about three thousand cases.

Post-partum Hemorrhage. The prophylaxis of post-partum hemor-
rhage consists in the proper management of the third stage of labor.
H. Fritsch2 says that if the uterus be massaged directly after the birth
of the child the placenta will partially separate, causing a failure of the
uterus to contract evenly, and will result in inevitable hemorrhage.
When after-pains occur the fundus of the uterus should be gently

1 Jour. Akoush. i. Gienskikh, Boliesney ; New York and Philadelphia Medical
Journal, September 5, 1903.

2 Deutsche rued. Woch., January 1, 1904.

MANAGEMENT OF THE THIRD STAGE OF LABOR. 241

rubbed with a circular motion for ten to twenty minutes after delivery.
If from auy cause there has been hemorrhage the uterus becomes atonic,
and hemorrhage is probably more often the cause of atony than the
result. Should post-partum hemorrhage occur from atony, the follow-
ing procedure, the writer claims, is safe and certain. The hands are
passed between the recti muscles to the back of the utents, and the
contained blood is expressed. The uterus is raised as high as possible
and forcibly anteflexed aud compressed against the posterior and supe-
rior surfaces of the pubes. The abdominal walls are easily forced
behind the uterus to the pelvic brim, and the resulting pouch of skin
and muscles is firmly packed with folded towels or cotton pads until
the uterus is immovably fixed against the pubes. A roller bandage or
one or two towels should be applied over the padding, thus forcing it
behind the uterus and toward the pelvic inlet. A towel or a bandage
should then be applied over the uterus to compress its walls, and may
be left for twelve hours. The foot of the bed should be raised ; hot-
water bottles, camphor, ergotine, ether, and normal saline solution used
as necessary. The following advantages are claimed for this method by
the writer : 1. That compression of the abdominal cavity forces the
blood to the upper half of the body, eveu more effectually than com-
pression of the abdominal aorta and bandaging of the legs. 2. Hem-
orrhage is impossible, on account of the pressure on the uterus obliter-
ating completely the uterine cavity. 3. Haamostasis is immediate. In
plugging the uterus with tampons large quantities of blood are
frequently lost. 4. No time is lost in rendering the hands aseptic,
as no internal manipulations are necessary. 5. When the pad is once
placed no further disturbance of the patient is necessary.

Post-partum hemorrhage from cervical lacerations is now more com-
mon than formerly, because of the practice of version and extraction
in eclampsia and placenta praevia before the os is dilated. A laceration
may be looked for when resistance to extraction suddenly yields, or if
hemorrhage immediately follows the birth of the child and the uterus
is well contracted. A cervical laceration is always on that side in
contact with the occiput, and is usually anterior to the uterine artery,
though this vessel may be torn through if there are parametric adhe-
sions. It was formerly the writer's practice to suture cervical lacera-
tions immediately, but many necropsies have convinced him that this
is not advisable. In deep lacerations extending above the supravaginal
portion of the cervix any attempt to suture involves danger to the
ureter, and is therefore difficult and probably useless. In plugging
lacerations where a large vessel is torn the hemorrhage is not arrested,
but may spread between the layers of the broad ligament or along the
course of the ureter. During plugging the hemorrhage continues.

16

!

242 OBSTETRICS.

The writer recommends " double compression " as the best method
of controlling hemorrhage from cervical lacerations. In this procedure
the placenta is removed, then, standing on the left side of the bed, the
uterus is grasped in the right hand of the accoucheur, anteflexed, and
pressed downward into the pelvis as far as possible ; this expresses the
coagula. The two labia tnajora are now seized between the fingers of
tin' left hand and forced up between the rami of the pubes. The entire
pelvic Boor is thus raised as high as possible into the pelvis, while the
labia are compressed tightly so as to allow no blood to escape externally.
This procedure is easy in a relaxed patient immediately after delivery.
The parts are then firmly compressed between the two hands as they
grasp them. Pressure is always made downward in the middle- line,
and should continue one-half to three-quarters of an hour, or even
longer. Should the right hand become exhausted it may be kept in
position by the nurse superimposing' her weight upon both hands
placed over it. The left baud may be assisted by propping the elbow
on the bed. Pressure in this manner is not painful ; the patient remains
quiet, and restoratives may be administered. When the hands are
removed — first the right, then the left — the uterus usually remains
deep in the pelvis, and there is no further hemorrhage. A sandbag
weighing about six pounds is placed over the uterus. The writer
claims to have arrested most alarming post-partum hemorrhages due to
laceration by this means in a few minutes. The following advantages
are claimed for the method : 1. There is no danger of infection, the
entire treatment being extravaginal. 2. The loss of blood, which
would occur in suturing or plugging, is obviated. 3. It is a rational

method, as it obliterates the spaces into which the blood would flow.

1. No after-treatment is required.

PUERPERAL INFECTION.

Prophylaxis. It is now generally agreed that the prevention of
puerperal infection requires a correct antepartum toilet ; efficient hand
sterilization and infrequent vaginal examinations ; the early repair of
injuries of the birth canal, and prompt investigation and treatment of
all cases of temperature elevation in the early puerperal period. The
antepartum toilet no longer requires antiseptic vaginal douches in
normal healthy women. Our efforts are to sterilize, as well as may be
done, by soap, water, and an antiseptic solution, the vulva, vaginal
entrance, and perineal and anal regions. The reduction to a minimum
of the number of vaginal examinations is favored by those obstetricians
of widest experience. The value of the sterilized rubber glove is
unmistakable to my mind, but there have appeared statistics show-

PUERrERAL INFECTION. 243

ing results no better than when careful hand sterilization has been
employed, and Sitsinsky,1 after investigating their value, concluded
that for a simple obstetrical examination they (1) give no particu-
lar advantage over a thoroughly sterilized hand, and are hard to
resterilize ; (2) the impairment of touch in versions and complex
examinations preclude their use ; (3) it may be necessary at times,
while working with gloves, to remove them and proceed without.
The accumulation of sweat and moisture contains a large number of
bacteria, even though the hands have been previously sterilized, and
renders this procedure actually dangerous ; (4) their use in general
may cause neglect of careful sterilization of hands as practised now.
In septic cases and septic operations he admits their advantage.

The objections named are certainly valid ones, but the dangers he
mentions must and can be avoided. Personally I have used rubber
gloves in all obstetrical and gynecological work during the past three
years, and I am convinced of their very great value. One must ever
bear in mind the valid objections noted above and the dangers of
repeated and unnecessary vaginal examinations, even with the gloved
hand. The vaginal entrance and perineal regions are the sources of
danger. They cannot be efficiently sterilized, and the gloved finger
must not come in contact with those parts oftener than necessary.

ZweifeP attributes the diminished percentage of puerperal fevers in
the Leipzig Hospital (a reduction in morbidity of 9.3 per cent, from
1898 to October, 1903) to the use of rubber gloves, and considers their
use indispensable. He also emphasizes the necessity for removing
from the uterus and vagina in the puerperium all blood clots by means
of dry aseptic sponges rather than by douches, and states that the
presence of clots favors putrefaction or infection. The percentage of
fever cases in well-conducted hospitals varies between 19 per cent,
and 28 per cent., despite the perfection of asepsis and antisepsis in
obstetrics. Following the careful removal of clots from the posterior
vaginal fornix in 243 cases, the morbidity was reduced to 5.7 per
cent., which is a reduction never before reached in his clinic. Mueller3
believes that clots retained in utero also give rise to fever, and he
removes these with his " rubbing catheter," which at the same time
stimulates uterine contractions. Bokelmann1 condemns such treatment
as meddlesome, and says Zweifcl has brought no proof to show that
coagula in the vagina produce fever by mild putrefaction. I believe
with him that the manipulations required for their removal are really
more dangerous than allowing the clots to remain until spontaneously

1 Jour. Akoush. i. Gienskikh, Bol., March, 1903.

2 Zentralblatt f. Gynakologie, May 28, 1904.

3 Ibid., July 2, 1904. * Ibid.

244

OBSTETRICS.

removed, except, of course, when an offensive odor unmistakably
announces putrefaction.

The proper time for repairs of injuries to the cervix, vagina, and peri-
neum lias received much discussion during the past year, and I have
referred to tin's topic in a preceding- section. The relation of these
injuries to infection is a close one, and offers, on the one hand, an argu-
ment in favor of immediate repair of the vagina, and, on the other
hand, an argument against too early repair of the cervix. Whether
it is wise to defer until the end of the first week the repair of all
injuries to the lower birth canal is not as yet definitely settled, and my
conviction is, for the present, that it is best for the general practitioner
to at once restore the vaginal and perineal lacerations as best he may,
and disregard the cervix until a later period.

Early recognition of infection and prompt intelligent treatment will
do much to prevent grave infection. Last year I commented on the
decline in the use of the curette, and pointed out the dangers of its
injudicious and indiscriminate use. I am convinced, however, that it
vet has a distinct field of usefulness. The practical principles govern-
ing the treatment of puerperal infection may briefly be summarized as
follows : Disinfect and remove, if possible, the focus of infection ; sus-
tain the patient's strength and fortify her for her struggle against the
invading poison, and try to combat the effects of absorbed toxins or
micro-organisms. All modern methods of attacking this disease aim to
accomplish one or all of those factors.

Strong antiseptic solutions for disinfecting the uterus and vagina,

such as bichloride of mercury, have been discarded in recent years.

When a disinfectant is desirable, as for sapraemia, Webster's formalin

solution :

Formalin ......... Tltxxx.

Glycerin . . . • . . • • • 1,5 1V>

Sterile water . . . . . . • • Qj.

or Schauta's iodine and alcohol solution :

Tincture of iodine 3J-

Alcohol and sterile water. ..... aa 5vn,].

has proven efficient and unattended with the danger of corrosive and
corroding solutions. Bearing in mind that, even in putrid endome-
tritis, the saprophytes and cocci have penetrated the superficial layers,
and in septic endometritis the pathogenic micro-organisms have invaded
the lymph and blood channels, and are far beyond the reach of the
douche, and, furthermore, the fact that within a few hours after irriga-
tion Kronig found streptococci as numerous as before the irrigation, it
is apparent that intrauterine douches have a limited field of usefulness.
One thorough disinfection usually accomplishes all the good to be

PUERPERAL INFECTION. 245

derived from douching at long intervals. Persistent offensive lochia
may require frequent irrigation, or even continuous irrigation, as
recommended by some writers. An antiseptic gauze pack may be sub-
stituted for frequent or continuous irrigation. Of the systemic means
employed for combating grave infection, antistreptococcic serum has
received little favorable comment, Raw1 reported 37 cases, all with
a bacteriological diagnosis, and believed the good result obtained
due to the serum. This is the only article I have seen that did not
condemn its use. Netter,2 Jaenicke,3 Yidal,4 and Schmidt5 have
recorded interesting results from the employment of colloidal silver.
Collargolum, one to two grains in a 2 to 5 per cent, watery solution,
is used for subcutaneous or intravenous injection ; unguentum Crede,
a 15 per cent, ointment in the dose of two to three drachms, is rubbed
into the skin for fifteen to thirty minutes three times a day.

I have used the Crede ointment in several cases, but associated with
so many other plans of treatment that I am unprepared to give an
estimate of its value, and I may say the same of antistreptococcic
serum. Personally, of all systemic treatment I have learned to place
more reliance on nourishing food, the free use of alcohol, and the sub-
cutaneous and rectal injection of normal salt solution made according
to Lacke's formula :

Sodium chloride ........ 3 lss-

Calcium chloride ....-••• »r- 'i-

Potassium chloride .....••• »r- lss-

Water (sterilized) ........ Oij.

H. Fehling6 advises the use of rubber gloves for all vaginal and
rectal examinations as a prevention of puerperal sepsis, and regards as
most dangerous the manual removal of the placenta. Massage of the
uterus or Credo's method should be tried before manual removal is
thought of, and this should only be done under most rigid asepsis.
The gloves should be sterilized before using them. He believes that
operative treatment of puerperal sepsis offers poor prospects, and has not
found colloidal silver administered by inunction of any value, but when
employed intravenously it has some value. He injects 10 c.c. to 20 <•.<••
of a 2 per cent, solution into a vein near the elbow, and has always
noted improvement in the pulse, temperature, and subjective symptoms.
The injections are repeated daily if necessary. He does not claim posi-

1 Journal of Obstet. and Gyn. of the British Empire, April, L904.

2 Bull, de la Sec- Med. des Hop. de Paris. January 22, 1903.

3 Deutsche med. Woch., February 5, 1903.

4 Prog. MeU, March 21, 1903.

5 Deutsche med. Woch., April 9 and 10, 1903.
,; Miinchener med. Woch., 1903, p. 1409.

2 it; OBSTETRICS.

tive cures for it, since some of his patients died in spite of it, l>ut nil eases
were at least temporarily improved.

Iodine Treatment of Puerperal Sepsis. The treatment of puer-
peral sepsis by packing the pelvis with iodoform gauze was the sub-
ject of a paper read before the Obstetrical Society of Philadelphia,
December 3, 1903, by W. K. Pryor.1 He said that of all forms of
puerperal sepsis 25 pel- cent, only were truly septic, and that it was
regrettable that there was such a lack of precision in diagnosis among
those who should lie better informed. Pyogenic bacteria are found
upon the vulva in To per cent, of cases, iu the vagina in about 30 per
(cut., and in the uterus in even an appreciable per cent, of normal eases.
Therefore, he insisted that for making a diagnosis of fever the method
of Doderlein of securing the contents of the uterus was the only accu-
rate one. Pyogenic cocci may act as saprophytes in the uterus as well
as producers of sepsis, and may change their role under the influence
of trauma. Therefore intrauterine irrigations and curettage were con-
demned in all cases where streptococci were present in the uterus.
Technical autoinfection, he believes, is very rare. The method of pro-
cedure is given in the event of the examination proving the case to be
one of sepsis. The uterus is washed out with Thiersch's solution, and
packed full of iodoform gauze of 10 to 20 per cent, strength. If the
case is saprophytic the temperature rapidly drops, and remains down.
If it drops and rises it is an indication that the pathogenic germs have
passed deeply into the uterine and parametric tissues. In his treat-
ment of these cases it is the author's object to secure local and general
iodism. He believes that in every case of true puerperal sepsis, sepsis
which does not yield to simple local cleanliness, peritonitis or adnexal
]esions are always produced, except in those rapidly fatal cases where
death takes place before local lesions can occur. We must also recog-
nize the destructive changes in heart, lung, and kidneys caused by the
septic process. In choosing a method of treatment we must attack
the disease within the pelvis and systemically ; this he endeavors to do
by isolating the infected uterus between the folds of iodoform gauze, in
order to destroy the cocci by the local and systemic iodism. The prep-
aration of the dressings is important. The best plain gauze, in five-yard
rolls, is sterilized, and then dipped into a 5 per cent, solution of iodo-
form crystals in ether. About one pound of the solution suffices for
five yards of gauze. The ether is then allowed to evaporate ; the gauze
when dry has a pale-blue tint, due to the action of the iodine upon the
starch in the cotton fibre. In this state the gauze is unfit for use ; it
is then dipped in a hot 1 : 4000 aqueous solution of bichloride of

1 Annals of ("iyn. and Ped., March, 1904.

PUERPERAL INFECTION. 247

mercury and wrung dry with the hands. The bichloride acts as a
fixing agent, and the gauze becomes the golden yellow characteristic
of iodoform. The dressings are then packed into jars and sterilized
for half an hour. When such a dressing is brought into contact with ,
an open wound or severed tissues very little iodoform is absorbed, but
when brought into contact with a serous surface its disintegration is
rapid, and the iodine becomes absorbed at once. The presence of
inflammation in the peritoneum, or a purulent effusion from the peri-
toneum, has no influence upon the process. Gauze treated by a 10 per
cent, strength solution is also prepared for use within the uterus.

The majority of his cases were brought to him after other measures
had failed to relieve. In all instances albumin was present in the
urine, in many grave kidney changes. Kidney elimination was aided
in the milder cases by high colon enemata of saline solution, in the
graver ones by intravenous infusion. The latter may be given before
the operation under local anaesthesia, during the operation or after.
He uses large quantities, the minimum being five pints, the maximum
eight pints. The cervix is dilated and the uterus curetted, a portion
of the detritus removed, being saved for examination. The uterus is
then freely irrigated with saline solution and packed full with 10 per
cent, strength iodoform gauze. The posterior cul-de-sac is then opened
by a broad incision. In all instances a quantity of fluid escapes, this
may be serum, serolymph, seropus, or almost pure pus. In case there
should be much effusion of lymph, and the organs are matted together,
all adhesions are rapidly broken up by the fingers. The uterus is now
lifted up and the posterior vaginal wall depressed. Generally the
rectum or a knuckle of intestine will present ; from the surface of either
a flake of lymph or some fluid is wiped off for examination. The
pelvis is now packed full of iodoform gauze of 5 per cent, strength.
As this folded dressing is withdrawn from the jar it is of one yard
width ; pieces eight inches long are cut off so that if they were
unfolded each would be eight inches wide by one yard long. They are,
however, inserted folded as when cut from the original piece ; from
ten to fifteen such pieces are used. The first is passed well to one side
of the pelvis over the iliac vessels and extending to the brim, it is held
in place by a long retractor. Other pieces are packed alongside so as
to completely fill the pelvis from side to side, be in apposition with the
posterior layers of the broad ligaments and uterus, and be in contact
with all that pelvic portion of the peritoneum which overlies those
lymphatics and veins which carry the infection. The gauze should
not project from the vulva. A self-retaining catheter is inserted, and
such cardiac stimulants employed as demanded. Ife uses nitro-
glycerin, <ligitalis, and moderate doses of strychnine. Massive doses

- IS OBSTETRICS.

of strychnine produce contraction of the arterioles, a most undesirable

condition in streptococcic infection. Frequently in two hours, but on
an average of five hours, a marked reaction of iodine is obtained.
Saline enemata arc given every four hours in eight-ounce quantities to
assist the kidneys In the elimination of the iodine. The posture of the
patient is immaterial. All dressings are examined bacteriologically.
I here is as the first reaction a free outpouring of serum by the perito-
neum ; this serum has a very strong iodine reaction. By examination
of tlic dressings he learned that the uterine cavity was sterilized with
more difficulty than the pelvic. In every instance, save one, the
pelvis was free from cocci at the second dressing; in this case strepto-
cocci persisted until the third dressing. In this case the conformation
<>f the cervix was such that it was deemed advisable to repack the
uterus at each dressing to keep the cervix open. In this case he found
streptococci upon the gauze from the fourth dressing of the uterus, but
not of the fifth. In this woman the drop in temperature after the oper-
ation was particularly sharp and abrupt, so that he had been led to
consider the sterilization of the pelvis as of more importance than that
of the uterine cavity. Although he had found streptococci in both
uterine and pelvic dressings, he had not failed to note the subsidence of
symptoms in all cases not having complications. He has never been
able to separate his cases into postpartum and post-abortum. He once
showed six uteri removed by the coroner from women who had died from
the most virulent septicaemia after clinical abortion before the fourth
month. Such cases could scarcely be left out of the class of puerperal
sepsis, and they are therefore so classified here. So many factors govern
the degree and progress of an infection that he had established a purely
arbitrary classification. All cases occurring after the tenth week of
pregnane v were included as puerperal. In 87 cases he had operated
upon, streptococci were found in the cul-de-sac in all. In 36 cases they
were found in the uterine scrapings. Torrens in six cases found
streptococci in the uterus and cul-de-sac. Killebrew has operated upon
2 cases, and Brooks H. AVells has performed 8 operations. In 10 cases
a previous curettage had been done and 3 died, a mortality of 33 per
cent. In 43 cases not previously operated upon the mortality was
2 per cent. Of those dying 1 had a bilateral bronchopneumonia, 3
endocarditis with pneumonia. As to the living, 6 subsequently con-
ceived, 5 going to full term, and 1 had an induced abortion at the fifth
month.

Contrast this treatment with that by curettage alone with a mortality
of 22 per cent. ; antistreptococcic serum, mortality 33 per cent. ; let-
alone treatment, mortality 7 to 25 per cent., and they had nothing for
which to apologize. But there is another phase. All the women they

PUERPERAL INFECTION. 249

operated upon who lived kept their uteri, aud six had had a restoration
to physiological function.

In discussion E. P. Davis said we must certainly include cases
of early abortion when speaking of puerperal septic infection. Cases
of sepsis after abortion and after childbirth have the same pathology
and require the same treatment. That septic infection rapidly passes
from the uterus had been fully confirmed by others. In a recent
report Treub, of Amsterdam, in 724 cases found but 6 in which
the infection was in the uterus, and of these six but 2 were appro-
priate cases for hysterectomy. In these 2 cases, upon which hys-
terectomy was performed, there was evidence that the infection had
spread beyond the uterine cavity. Hence, treatment based upon
the belief that the uterus is the site of the infection must be un-
successful. A sudden drop in temperature may follow prolonged irri-
gation of a septic uterus or abdominal section, with irrigation of the
pelvic or peritoneal cavity. This result, then, cannot be ascribed
entirely to the iodine. In comparison with the results of hysterectomy
Davis considers Pryor's results highly favorable.

The total mortality of Treub's 724 cases of septic puerperal infection
was 4 J per cent, without operation. Fehling reported 61 cases of
hysterectomy for septic puerperal infection with a mortality of 55.7
per cent. Leopold places such restrictions upon the selection of hys-
terectomy in septic cases as to render the operation an exceedingly
rare one. Davis considered that some of the benefit in Pryor's
cases was due to the curetting, and believes that when the operator is
prepared to drain the pelvic cavity antiseptically curetting should
precede the operation for drainage. In skilful hands the uterus may
be emptied of necrotic tissue without breaking down the zone of resist-
ance or imperiling the patient's interests. In view of the fact that
bacteriology shows us that the birth canal frequently contains bacteria, we
must consider the uterus as already infected in cases where interference
has been practised without strict antisepsis. When we deliver these
cases by craniotomies after forceps have been unsuccessfully applied
we should drain the uterus after delivery by a packing of iodoform
gauze. Hemorrhage is not only prevented, but we anticipate the
development of an infection, and do something to prevent it. It is not
unusual that patients so treated make an uninterrupted convalescence.

Montgomery also agreed as to the extension of the infection through
the uterine walls into the peritoneum, and said that in cases where one
found no evidences of there being an infiltrate about the uterus, on
opening the retrouterine sac we find the peritoneum not only covered
with a serous exudate, but not infrequently a seropurulent fluid. He
cited a case which recently came under his care. The temperature

250 OBSTETRICS.

was 104° j examination disclosed the absence of anything within the
uterine cavity, and there was no sign of any exudate or infiltrate aboul
the uterus. Doug-las' pouch was opened and there was at once a con-
siderable discharge of a seropurulent fluid, so irritating' in eharacter
that his fingers, which had previously been pretty thoroughly scrubbed,
were blistered by the infection within twenty-four hours. The irriga-
tion of this cavity with normal salt solution and subsequent packing
with iodoform gauze resulted in the patient's recovery after a prolonged
convalescence. In many cases of high temperature, defective kidney
action, and defective elimination, intravenous injection of saline solu-
tion seems to afford the most favorable outlook for the recovery of the
patient.

In discussing this paper I said that I regarded this method as a dis-
tinct advance in the investigation of the surgical treatment of puerperal
septicaemia. Heretofore even aggressive surgeons operating upon grave
cases of puerperal sepsis had not achieved brilliant results. Unfortu-
natelv, the same doubtful element of diagnosis and prognosis which limits
the performance of hysterectomy and often the use of the uterine
curette will be found to exist in cases treated by this method. Nowa-
days, as grave septic cases have almost entirely disappeared from mater-
nity hospitals, one must, to estimate its practical value, judge this
method by what the general practitioner can do with it, and I wish to
sound a note of caution concerning the dangers attached thereto in the
hands of the general practitioner. Bacteriological examinations in
puerperal septicaemia, of the vaginal secretions, uterine contents, and
even of the blood, have practically not accomplished anything in the
treatment and prognosis of individual cases. We have one woman
with streptococci in her uterus or blood, and hysterectomy is done, and
she dies ; another under the same conditions, and she gets well, not
ahvays because of hysterectomy, but because of some resistance to the
infection in her body. Bacteriological investigations advance our
knowledge, but the progressive surgeon in puerperal septic cases must
finally be governed by other factors. If the general practitioner in
his private cases were to open the cul-de-sac in the presence of a less
serious type of infection, and pack with gauze in the presence of an
infection which may not have spread to the pelvic cavity, there is
added a distinct danger, as witness the indiscriminate use of the curette.

The practical value of any method of treatment must be measured
largely by its value to the general practitioner, and therefore the
inability of such men to make bacteriological examinations will render
Pryor's method a dangerous plan in their hands. Bacteriology has
not yet determined for us the necessity or contraindication for the
surgical treatment of puerperal sepsis. That is true of the curette, of

PUERPERAL INFECTION. 251

hysterectomy, of excision of thrombosed pelvic wins, as recommended
by Trendelenburg, of this operation of Pryor's, or of any surgical
treatment ever advocated. Until the bacteriologist can give us more
than an anatomical diagnosis of the kind of organism, we can look for
little aid from that quarter. The mere diagnosis of a streptococcus
under the microscope will not tell us the virulence of that particular
germ ; it must be subjected to animal inoculation to determine its
pathogenic potentialities. Because we have anatomically diagnosed a
streptococcus we cannot claim that our treatment, because apparently
successful, has saved life. The difference in the power of resistance in
the organisms of individuals to streptococci ; the difference in the viru-
lence of the different varieties of streptococci ; the difference in the
channels through which streptococci may invade the system ; when
bacteriology may tell us those important factors in every case, then
will it be of value. Men of large clinical experience with the strepto-
coccus find that it is not as virulent in one case as in another, and yet
there is no difference between the micro-organisms under the microscope.
The clinical diagnosis of the channels through which infection is
spreading is of far greater value, both for treatment and for prognosis.
Determine by bacteriology, by surgery, or clinical signs, if possible,
where the infection is spreading or is localized, and then your treatment
may avail or its hopelessness be disclosed. In the very rare cases of
peritonitis yet localized in the pelvis, due to microbe invasion through
the tubes or uterine wall, drainage of the cul-de-sac by Pryor's treat-
ment would doubtless be ideal, but such cases are rare, and practically
defy diagnosis at the time when treatment would avail. Pryor records
three cases which, in spite of his attempt to localize the infection in
the pelvis, died from systemic infection. What, then, is the practical
value of attempting to localize the disease in the pelvis and drain the
pelvic cavity free from germs if we are to have our patients die of strep-
tococcic endocarditis or pneumonia '? If iodine is the agent we employ,
why introduce it into the pelvic cavity when it is not going to reach
the infection which has passed beyond the pelvic cavity ? Why not
attempt intravenous injection at once, as has been followed by failure
with formalin ? May it not be that the curettage and uterine drainage
are responsible for a part of the good results obtained? If virulent
streptococcic infection has passed beyond the uterine cavity, which is
sometimes a question of minutes, it has gone beyond the possibility of
localizing it to the pelvis, and this treatment will fail. We must,
however, recognize a limited value for this method in skilled hands,
among the methods of preventing grave cases, especially when we
learn to differentiate and recognize the class of cases that drainage of
the cul-de-sac will save by preventing a local from becoming a general

252 OBSTETRICS.

an.l fatal peritonitis. For the cure or the prevention of the rapidly
fatal systemic infections through cither the lymphatic or venous
channels 1 cannot sec its value.

J. G. Clark' commended the procedure up to the point of opening
the cul-de-sac and packing in eases seriously threatening puerperal in-
fection, but he believed too sweeping assertions were made as to the route
of infection without more definite scientific data. From the anatomical
standpoint there are but two ways in which Douglas' cul-de-sac can be
infected from the uterus : first, by direct continuity from the uterine
mucosa out through the Fallopian tube; second, the direct penetration
from the uterine mucosa, through the uterine muscle and peritoneum
into this cavity. That the streptococcus, which is a non-motile organ-
ism, should be so marvellously transported, even by the blood or
lymph st reams, as has been described by Pryor, is scientifically in-
conceivable. If the treatment depends for its efficacy upon the evacu-
ation of infectious matter from Douglas' cul-de-sac, then it is entirely
rational; if, on the other hand, Pryor expects to directly affect the
lymph stream flowing through the broad ligaments and retroperitoueally
along the line of the iliac vessels, it would appear that his assumption
was open to serious question. First, the peritoneum of Douglas' cul-
de-sac is a non-absorbable area, and therefore the mere application of
iodoform gauze over the peritoneum in proximity to the broad ligament
could hardly affect the therapeutic end, which, he believes, he has
noted in these cases. The position Clark took was that the argument
was strongly in favor of the plan instituted, but scientifically Pryor's
position was by no means yet assured. He would unhesitatingly
adopt it in properly selected puerperally infected cases. So far as the
use of iodoform gauze was concerned, he attributed nothing of curative
value to it. C. P. Noble asked how one could be certain the results
obtained were due to iodoform gauze and not to drainage. For the
past six or eight years he has not used iodoform gauze, and cannot see
the slightest difference in his results since discontinuing its use. It
seems a fair question whether the results obtained have not been due to
the drainage per se, and not at all due to the iodine. He believed
that Pryor's results would have been as good or better if most of the
cases had been treated medically and those in which an abscess formed
had been treated by drainage.

Baldy expressed himself as having no faith in the theory that the
streptococci pass directly through the wall of the uterus iuto the
peritoneal cavity. The infection is through the Fallopian tube, or
the lymph channels, or bloodvessels into the general circulation. He

1 Loc. cit.

PUERPERAL INFECTION. 253

believes that the rapid improvement of symptoms is clue to the drain-
age of the serum from the pelvic cavity ; that such improvement is
exactly what we see in septic accumulations of similar character after
operations, and that the drainage of the serum through the patulous
opening in the cul-de-sac is the large element of success, and that the
iodoform packing has nothing to do with it. Altogether, he considers
the treatment good.

Regarding the value of bacteriology in obstetrics, Pryor said, in
closing the discussion, if you examine the discharges of a woman and
find no streptococci, aud curette her she will get well. If the dis-
charge shows streptococci aud you curette you will lose 22 per cent, of
your cases.

Much antistreptococcus serum has been sold. Iu 251 cases iu which
bacteriological examinations were not made there was a mortality of
15.85 per cent., while with bacteriological examination that showed
streptococci there was 33 per cent, mortality. It has taught the general
practitioner not to curette when streptococci are not present.

Bacteriology in obstetrics is of the utmost value to us. The question
is still to be decided as to the best technique to get these discharges.
He would not be willing to go back to empiricism and ignore the
scientific work done.

Bacteriology of the Puerperal Uterus. One of the most vitally im-
portant subjects awaiting final settlement is the question of the presence
or absence of micro-organisms in the normal puerperal uterus. At the
present time the statements made by various investigators are contra-
dictory in the extreme, some claiming that the presence of pathogenic
organisms within its cavity is of the most serious diagnostic moment
and resting their choice of treatment upon the bacteriological findings,
while others claim that such a stand is " ultrascientiflc," and point to
cases in which the presence of streptococci in the uterus did not
interfere with the course of a normal puerperium. The importance of
this matter needs no explanation, and Marx1 deserves praise for his
painstaking study. He found in a series of cases a marked uniformity
in his results. It is to be noted that his study was based upon fifteen
consecutive, and therefore not selected, cases of labor. The greatest
care was exercised to prevent contamination from cervix and vagina,
and cultures were taken a number of times in each case at intervals
during the puerperium. If the first three cultures were negative (they
were taken on alternate days), no others were taken unless the case
showed subsequent temperature rise. In only two of the cultures made
were positive results obtained. Both of these showed the presence of

1 American Journal of Obstetrics, September, 1903.

254 OBSTETRICS.

staphylococci and streptococci, bui in each a fault in technique was
recognized as the cause, and its correction in the subsequent tests gave
negative findings in both cases. Marx concludes that the normal puer-
peral uterus is free from pathogenic organisms, and if such are found
they show faulty technique. If, moreover, there be fever, but nega-
tive results on culture from the cavity of the uterus, the cause of the
temperature will be found in some organ other than the uterus.

Tt must be remembered, however, that while the uterus in a normal
case can be considered sterile, and that bacterial growth is inhibited
in the vagina, the vulva, on the contrary, is a fruitful soil for the
development of micro-organisms, and therefore its most careful cleansing
is required in all eases of labor.

Rational Treatment of Puerperal Infection. H. G. Weth-
erell1 condemns prophylaxis which is not practised consistentlv.
People of moderate or poor circumstances who are not able to secure
asepsis in their homes should be removed to hospitals. Rubber gloves
should be u<vi\ and fewer vaginal examinations made. The curette is
dangerous, and does a vast amount of harm in all cases of true septic-
aemia by opening up new areas of absorption and aiding in the dissemi-
nation and distribution of the infectious material. Anaesthesia adds
work to a kidney already taxed to its limit, and he believes when the
pulse is over 120 an anaesthetic should not be given. Antiseptic
solutions may do good if used judiciously. These are, however,
capable of much harm, and are now supplanted by safer, better, and
more easily applied means. Antistreptococcic serum and unguentum
Cred6 are both condemned. Laxatives and purgatives are condemned
because they weaken the patient. Whiskey, caffeine, sparteine, digitalis,
quinine, and adrenalin chloride are all good and valuable sustainers in
conjunction with other lines of treatment. The same methods of treat-
ment should be applied as are used in other intra-abdominal infections,
with the additional use of drainage tubes and intrauterine irrigations
of alcohol as advocated by Carossa. Tubes and gauze may be left in
place from two days to two weeks. If the treatment be instituted suffi-
ciently early, that is, before general sepsis and diffuse peritonitis are
e-tablished, the temperature, pulse, and general expression of the
disease are rapidly altered for the better.

Hysterectomy for Puerperal Infection. It is pretty generally
agreed that this operation has a very limited value. Since the discus-
sion at the Fourth International Congress of Obstetrics and Gynecology,
and the restrictions then placed upon hysterectomy by Leopold, no writer
has advocated for it a very wide range of usefulness. Fehling reported

1 American Journal of Obstetrics, May, 1903.

PUERPERAL INFECTION. 255

1)1 cases with a mortality of 55.7 per cent. During the past year I
have had 3 cases in which the operation seemed justifiable, but in each
case grave systemic infection antedated the operation, and the patients
succumbed after an operative recovery. There are, however, those
who yet maintain its usefulness, and in a certain restricted class of cases
it holds its place. Valere Cocq1 claims, as a general rule, that hys-
terectomy is indicated when there is a grave toxaemia or when the
uterus has in all probability become the chief entrance of the septic
material, and, other means of treatment having failed, the patient is
still strong enough to withstand the operation. These conditions are
found in certain cases where the placenta has been retained and is
undergoing decomposition and cannot be removed by the curette ; in
cases of suppurative metritis where fibroids have undergone prolonged
compression during labor, causing degeneration and a clogging of the
flow of the lochia by their rough surfaces and also destroying the endo-
metrium, thereby facilitating the reabsorption of the products. In
streptococcic septicemia, though macroscopically no lesion is seen in
the uterus, microscopically it is thronged with the organisms; hyster-
ectomy exerts a most favorable aspect upon the final outcome. In
cases where there is extensive involvement of the parametrium and
adnexe, though they are often treated with ice and opium in the hope
of avoiding an operation, the radical operation sooner or later is found
to be necessary to save the life of the patient.

After a careful and searching analysis of mortality records, Pinard2
condemns this operation. In the Baudelocque clinic from 1893 to
1 903 the percentage of deaths from genuine puerperal septicemia was
0.25, or, to give figures, 69 deaths in 26,952 labors. Two cases upon
which hysterectomy was performed perished. The first one was oper-
ated upon the tenth day of the infection, and died four days later.
When the uterus was removed the infection was thought to be a sup-
purative thrombophlebitis limited to that organ, but the autopsy later
revealed streptococcic pus in the left pleura. In the second one a
supravaginal hysterectomy was performed, leaving the cervical stump
and draining the abdomen. The patient lived two weeks. The
writer emphasizes the facts that in the majority of autopsies in no case
was the infection ever found localized in the uterus, and that the
bacteriological examination of the blood did not favor hysterectomy.
In two cases the focus of infection was discovered, post-mortem, to be
in sloughing fibroids, they not being diagnosed during life, lie also
says that in none of the fatal cases were the clinical symptoms such as

1 Gaz. de Gyn., April 1 and 15, 1903.
- Ann. de Gyn. et d'Obstet,, April, 1903.

256 OBSTETRICS.

to indicate the uterus as the only source of infection or that the
uterine lesions were unsuitable for treatment less radical than hyster-
ectomy.

Vineberg,1 discussing this subject, says that no one micro-oganism can
be held as causative in the production. Attempts to diagnose and
prognosticate upon the basis of the bacteriological findings in lochia
or uterus have been shown to be absolutely fallacious. Thus Fehling,
in opening the discussion at the Fourth International Congress of
Obstetrics and Gynecology, in Rome2 in 1902, calls attention to the
fact that both streptococci and staphylococci have been found in the
uterine cavity in cases which have run an absolutely normal course,
while in severe forms of infection either streptococci, staphylococci,
bacilli eoli communis, as well as mixed infections, may be found. The
same unreliability is also fouud in the case of the blood. Boldt3 at one
time believed that the presence of pathogenic germs in the blood was
an indication for hysterectomy, but further study has demonstrated that
the blood may be entirely negative in the presence of fatal sepsis, and,
moreover, that mild cases recovering without operative interference may
show germs in the blood stream. It must, therefore, be conceded that
treatment cannot unfortunately be based upon the bacteriological find-
ings in any given case.

While it is true that in the majority of cases any septic manifestations
in the course of the puerperal period may be rightfully considered as
due to infection transmitted through carelessness on the part of some
of the attendants upon the case, it is, nevertheless, to be remembered
that investigations have shown the presence of pathogenic germs in the
vaginal tract of an appreciable number of pregnant women, and there-
fore the teaching at present in vogue should be modified to agree with
the actual facts. Such modification need not and must not in any
way belittle the importance of rigid asepsis. It would, however, by
removing the absolute stigma of culpability at present attaching to
the attendants concerned in a septic case, lead to the proper diagnosis
being made and appropriate treatment being instituted at any early
period.

In consideration of the treatment of sepsis, while certain phases are
still mooted questions, there are others regarding which the consensus
of opinion is practically unanimous, as, for instance, the use of cauteri-
zation and free drainage in dealing with wounds of the perineum,
vulva, and vaginal tracts, the advisability of the removal from the
uterus of any retained and infected tissues, either placental or decidual.

1 American Journal of Obstetrics, 1903, vol. xlviii., No. 3.

2 Monats. f. Geb. u. Gyn., Bd. xvi.

3 New York Medical Journal, January 26, 1901.

PUERPERAL INFECTION. 257

So, too, the ablation of the uterus containing sloughing tissues so
adherent that removal by intrauterine manipulation is impossible, or
presenting a submucous sloughing fibroid. Moreover, in cases in
which the uterine substance is studded with small abscesses there is no
dissenting opinion as to the advisability of hysterectomy, provided that
the diagnosis can be made at a proper time.

Certain cases of sepsis manifest themselves by the production of one
or more abscesses in relation to the uterus, either in its substance or in
the parametrial tissues, and there also the methods advocated will be
found to be nearly identical among various operators. There is one
class of cases, however, namely, septic endometritis, in which the treat-
ment is causing marked differences of opinion regarding the advisability
of hysterectomy. These cases, if intelligently treated from the start,
need never become so serious as to indicate the possibility of hysterec-
tomy, since it may be stated with assurance that septic puerperal endo-
metritis is very rare unless as a complication of retained placental
residue. If the proper treatment, namely, emptying the uterus, be
instituted the question of hysterectomy would never demand discussion.
The difficulty here is to decide upon the proper time to operate, to avoid
the criminality of operating too early, but at the same time avoiding the
danger of withholding interference until too late.

In considering this question it must be remembered that in a large
proportion of these cases if recovery ensues it is only partial, the repro-
ductive organs being left in a condition of disease necessitating later
operative intervention. If in such cases hysterectomy be deemed advis-
able, the abdominal route should be chosen in order to remove more
satisfactorily the infiltrated broad ligaments and to avoid hemorrhage.
It is important that in these cases a complete removal should be done
in order to remove all the infected area and also to allow for drainage
of the broad ligament stumps.

In operating for the relief of a more or less general peritonitis it is
to be remembered that time is a most important element. If interven-
tion be practised within forty-eight hours after onset there may be some
hope of success. If, however, the entire peritoneum has become
affected any method of treatment will probably fail.

The ligation of the uterine and ovarian veins when the scat of throm-
botic infection, after the method of Trendelenburg and Zweifel, is worthy
of further trial, as it is based upon sound surgical principles.

As regards the general remedies to be used, they are the ones accepted
by the profession at large, with the comment that unguent Credl
possesses possible powers in aiding elimination of the toxins or in counter-
acting their bad effects. It is well to use it in cases in which no
source of infection can be found requiring surgical intervention or

17

258 OBSTETRICS.

where such lesions having been removed the septic manifestations
continue.

Treatment of Pyaemia. Opitz1 describes Olshausen's treatment of
puerperal pyaemia. Nourishing food, as milk, eggs, and various albu-
min preparations (puro, plasmon, somatose, etc.), and especially sugar
to supply calories and create thirst, are freely administered. The
drinking of large quantities of water and two or three rectal injections
of physiological salt solution (500 v. v.) promotes diuresis and elimination
of the products of metabolism and of toxins. Absolute rest and quiet
arc most important in aiding nature to localize foci of infection.
Placing the patient upon a thick layer of sterilized clay will prevent
bed-sores. Dee}> inspirations for a few minutes several times a day
improves the oxygenation of the blood and helps to prevent hypostatic
congestion and to avoid pneumonia. Alcohol in large quantities is
never given, and surgical treatment is rarely indicated. He favors the
systematic use of nuclein as recommended by Hofbauer, and, while
having had little personal experience with the intravenous injections of
collargol, suggests using them.

Gonorrhoea during Pregnancy and the Puerperium. Fruehins-
holz- states that lie found gonorrhoea present in 20 to 25 per cent, of
pregnant women ; that pregnancy is not prevented by acute gonorrhoea,
and often causes the development of latent symptoms ; that, as a rule,
it does not cause abortion, but when the latter occurs gonococci are
frequently found in the placenta and decidua. In the puerperal period
the gonococci rapidly multiply, and in some cases are the cause of
puerperal infection. His investigations confirmed the belief that so-
called puerperal rheumatism is usually the result of infection with
gonococci.

Taussig3 calls attention to the fact that the lighting up of a latent
gonorrhoea! process after labor may cause symptoms which closely re-
semble streptococcic puerperal fever. This occurrence, he believes, is
more frequent than is generally supposed, and the symptoms arising
from it are so serious that a closer study is demanded. The author
presents a number of case-histories and also summarizes the litera-
ture. His conclusions follow : 1. That in about one-sixth of all the
cases of puerperal infection the gonococcus is the etiological factor.
2. While the infection is usually secondary to a gonorrhceal process
elsewhere, it usually follows puerperal wounds, and hence must be
classed under the head of puerperal fever. 3. The gonococcus may
gain entrance to the uterine cavity when no internal examination has

1 Deutsche med. Wochen., xxx., Nos. 26 and 27.

2 Zentralblatt f. Gynakologie, 1903, No. 45.
: American Gynecol., April, 1903.

PUERPERAL INFECTION. 259

been made ; this explains the cases of so-called autogenous infection.
4. The infection more frequently results from digital examina-
tions or operative manipulations. 5. The infection shows pus the
sixth or eighth day after delivery. It is characterized by rigors and
a temperature of 103°, with accompanying severe abdominal pain.
The duration of the fever is usually short. The disease assumes
a milder course, and usually becomes chronic. 6. Those cases in
which the fever rises to 103° and 104° as early as the sixth day are
not necessarily caused by a mixed infection, but may be caused by
the gonococcus alone. 7. The diagnosis is based on the late onset,
the slow, regular pulse, the moderate and steady elevation of the
temperature, a profuse, purulent, glairy discharge containing the
gonococcus. 8. Prophylaxis should be strictly observed, as it is of
more beuefit than treatment. No internal examination should be
made in those patients with gonorrhoea. Treatment should consist in
one or two intrauterine douches, frequent vaginal irrigation, and rest
in bed for a long period.

Statistics on Puerperal Fever. From his clinic in Strassbnrg,
H. Fehling1 reports a series of 377 cases of infective puerperal condi-
tions treated during the past ten years. As one would expect from
hospital management in recent years, only a small proportion of the
cases originated in the hospital maternity department, the majority
being infected on admission. Of the total number of cases 17.7 per
cent. died. In 25.8 per cent, of cases some form of intervention had
taken place. This included manual extraction of the placenta, forceps,
version, breech delivery, and perforation. Of the cases delivered
spontaneously 11 per cent, died, while 29 per cent, of those delivered
by operations died. In the fatal cases pyemia was the cause of death
in 38.8 percent.; sepsis in 26.9 percent.; septicopyemia in 14.9 per
cent. ; peritonitis in 8.9 per cent.; parametritis in 4.5 per cent. ; tumor
of the appendages in 3 per cent.; endometritis in H percent.; sup-
purating ovarian cystoma in 1 J per cent. All the cases of septico-
pyemia ended fatally ; of the septic cases 85.7 per cent, died ; of the
peritonitis cases 85.5 per cent., while of the pyemic cases 72 per cent,
ended fatally. The author in announcing these figures calls attention
to the point that they proclaim. Manual separation of the placenta
should be practised as rarely as possible. The proper management of
the third stage of labor demands more care and skill than are usually
devoted to it. An expectant treatment is advised. Should severe
atonic hemorrhage occur the uterus should be massaged; in case this
procedure does not control it practice premature expression. When

1 Munch, med. Woch., August 18, 1!)0.°,.

260 OBSTETRICS.

the pains are weak and always in placenta prsevia he uses the Crede
method of expression ; should this fail an opiate is administered and
expression is applied. In the small number of eases in which it will
lie necessary to remove the placenta manually it should he done under
thoroughly aseptic conditions. Hands, vulva, mons veneris, thighs,
ami vagina and uterus, as far as possible, should be disinfected. Sterile
gauze should be used to cover the anal region during the manipulations.
In a series of experiments with and without rubber gloves it was found
there was no material difference in the number of infected cases in a
year's work with the two methods. Rubber gloves are very liable to
tear in version, forceps operation, etc., and dull one's sense of touch.
Therefore, he believes that in all examinations save in actual labor,
and particularly where there is pus present, gloves should be worn.
Then when one has to attend a labor no infection will be carried to it.
Only in cases where you have knowingly been in contact with infec-
tion should rubber gloves be worn. Of the treatment of puerperal
infections, parametric abscesses are to be opened most commonly just
above Poupart's ligament. Even in severe cases hysterectomy is use-
less, as the infection has spread beyond the limit of the uterus. As to
the excision of thrombosis in pysemic conditions, he is very guarded.
Credo's colloidal silver has not proven of any benefit in his hands.

Puerperal Tetanus. Cases of this very fatal form of puerperal
infection are by no means rare. I have seen two cases in consultation
during the past year, both following abortions and intrauterine manip-
ulation. AVurdock1 reports a case following the delivery of a macerated
and decomposed foetus, the placenta having been manually removed
three hours later and the uterus washed out. The patient had an
elevated temperature for four days, which gradually disappeared, and
she was discharged on the tenth day. The following day the classical
symptoms of tetanus appeared and rapidly increased in severity.
Tetanus antitoxin and urethran were administered without avail, and
death occurred on the sixteenth day after her delivery. The diagnosis
was made upon the clinical signs and the bacteriological examination, the
inoculation test upon animals being negative. The increasing popu-
larity of spinal puncture and injection, the frequent failure of anti-
tetanic serum, the high mortality of puerperal tetanus, and Murphy's2
case of traumatic tetanus successfully treated by aspiration of the
cerebrospinal fluid and injection of morphine, eucaine, and salt solution
all indicate that in this method we may find a treatment that will be
of signal service in tin; treatment of puerperal tetanus. In Murphy's

1 Prager medicinische Wochenschrift, 11)03, Nos. '■> ami Id.

3 Journal of the American Medical Association, August 13, 1904,

gr. iss.

09

gr. h

02

gr- iij-

18

f 5 iiiss.

105

PUERPERAL INFECTION. 261

case after lumbar puncture 16 c.c. of cloudy cerebrospinal fluid were
withdrawn and 3 c.c. of the following solution were injected :

H — Eucaine .......

Morphinse sulphatis ....

Sodii chloridi ......

Aquae destillat. .....

This solution is sterilized by boiling. The withdrawal of 15 c.c.
of cerebrospinal fluid followed immediately by injection of 4 c.c. of
the above formula was practised daily during four days and twice at
intervals of two days. The quantity of morphine (-j\ of a grain)
and of eucaine ^A of a grain) in each injection was small, and he
believes that the strength of the eucaine in the solution should be
increased, so that the patient would receive ^ or even | of a grain
with each injection, and that the aspirations and injections might be
repeated more frequently. Whether the benefit was attributable to
the extraction of the cerebrospinal fluid or to the injection of the solu-
tion, or both, it is impossible to say. The fact that the fluid with-
drawn on the first, second, and third days contained pus, and after
that none, would lead oue to believe that possibly the diminution of
pressure in the cerebrospinal cavities aided the fluid in overcoming the
infection, just as in epidemic cerebrospinal meningitis repeated spinal
puncture relieves the pressure, and gives the greatest percentage of
recoveries. Helme1 has used, with success, spinal subarachnoid punc-
ture for the treatment of eclampsia. Suggesting that the convulsions
in that disease are due to increased cerebrospinal tension, he treated a
case by withdrawal of one and one-half drachms of cerebrospinal fluid.
The convulsions were relieved, and the patient recovered.

Abscess of the Uterus during the Puerperium. This condition
is so rare that the case reported by Lea2 is rendered exceedingly inter-
esting. The patient, an VHI-para, was suffering from gonorrhoea
when delivered, and the abscess developed during the puerperium.
During the later months of pregnancy she had had a profuse yellow
discharge from the vagina, but was not treated for it. She was
attended by a midwife in a normal delivery. Three days later the
child developed severe ophthalmia in both eyes. During the puer-
perium the mother's condition remained good until the twelfth day,
then she was seized with severe hypogastric pain, but was able to be
up. The pain continued until May 17th, six weeks after delivery,
when she was suddenly seized with severe pain in the lower abdomen
accompanied by a severe rigor; temperature 103.6°, pulse 130. The

1 British Medical Journal, May 14, 1904.

* Journal of Obstetrics and (lynecology, British Empire, February, 1904.

202 OBSTETRICS.

abdomeD was extremely tender and distended below the umbilicus.
Vaginal examination revealed a soft, bulky, slightly mobile, anteflexed
and very sensitive uterus. Twelve hours later her condition was
much worse: temperature 104.2°, pulse 140, with embarrassed respi-
ration. The abdomen was generally distended, bilious vomiting had
become incessant, and she had a dry tongue. Abdominal section was
done. Upon making the incision pus was seen around the uterus and
upon the intestines. Upon separating coils of bowel slightly adherent
to the fundus about four ounces of thick pus escaped. The finger
passed into an abscess cavity opening one inch below the fundus poste-
riorly. The cavity was irregular in shape, with soft, infiltrated edges.
During the manipulations the finger passed into the uterine cavity.
The left appendages were normal, the right were apparently normal,
but, as they had become covered with pus and yellow lymph and were
probably infected, they were removed. The uterus, being otherwise
healthy, was allowed to remain. During this part of the operation the
peritoneal cavity was continuously irrigated with normal saline solu-
tion. Post-vaginal section was then performed, and a soft rubber tube
passed from the lower part of the abdominal wound into the vagina.

The abscess cavity in the uterine wall was packed with iodoform
gauze, which also loosely filled Douglas' cul-de-sac and was brought
out into the vagina. The gauze was removed on the fourth day, and
the rubber tube finally at the end of three weeks by gradual shorten-
ing from below. The patient made a good recovery, and an examina-
tion December 28, 1903, revealed a uterus normal in size, anteflexed,
and freely movable.

Metritis Dessicans Puerperalis. Separation of a portion of the
uterine wall following infection has occasionally been reported, and
Gottschalk,1 in reporting a case eighteen days after severe puerperal
infection, calls attention to the injurious action of strong antiseptic
injections in the treatment of septic endometritis, the trauma of the
former and the infection being the two important factors in producing
this result. In his case a foul and necrotic portion of the uterine
wall was discharged, measuring 10 x 4 x 2 J cm. The diagnosis of
this type of infection is well-nigh impossible. Gottschalk has observed
a rapidity and smallness of the pulse out of all proportion to the tem-
perature, which undergoes only slight morning remissions. The
increased size of the uterus, the marked tenderness, and the late
offensive discharge are suggestive.

Phlegmasia Alba Dolens. The etiology of this affection is
generally recognized as due to thrombophlebitis. Stowe2 points out

1 Zeits. f. Gyniikol., 1904, No. 23. 2 New York Med. Journal, August 15, 1903.

PUERPERAL INFECTION. 263

the fact that thrombophlebitis frequently occurs without the symptoms
of phlegmasia, and, with Tilbury Fox, believes that obstructive lymph-
angitis is the hitherto unknown factor. When a clot forms in the
femoral vein the congestion during the establishment of the anasto-
moses is intense, and serum and red blood cells find their way into
the adjacent tissues. The lymphatics, if active, rapidly absorb the
exudate, but if they fail to do their work lymph accumulates in the
tissues, and its fibrinogen, fibriuoplasten, and fibrin ferment acting
upon the extravasated blood serum, a gelatinoid substance is formed
which is the transudate formed in phlegmasia. In additiou to the
usual treatment, he recommends the application, for an hour daily, of hot
dry air (400°), to be followed at a later period by massage.

Laws of Puerperal Immunity. The following laws regarding
immunity in cases of puerperal infection are presented by E. Couninas i1
1. A puerperal woman affected with acute mammitis never dies of
puerperal infection. 2. A puerperal woman affected with acute sup-
purative mammitis is never mortally infected with her own pus. The
second law is a consequence of the first, and is of great practical and
theoretical importance. Notwithstanding the many chances that a
woman with a suppurating mammary abscess will convey pus to the
genital canal, the author affirms from clinical observation that such
reinfection is very rare and never fatal. Further, febrile metritis and
vaginitis accompanied by mammitis never prove fatal ; and this holds
good, whether the mammitis be suppurative or not, and whether it
precedes or follows infection of the genital canal. In explanation
of these facts the author advances the following hypothesis : that
when a mammitis precedes genital infection the virulence of the
bacteria causing it is attenuated by the product of the glandular inflam-
mation, so that, though general infection may exist, as attested by the
general symptoms, notably the fever, a fatal issue is not seen. In
other words, the products elaborated in the mammary focus lend to
the organism a relative immunity. When a mammitis occurs in a
puerperal patient whose genital canal is already infected, the products
elaborated in the mammary focus pass to the blood, and in this case
also bring about such a modification of the organism as to preclude the
possibility of a fatal outcome to the primary infection. The immunity
conferred under these different circumstances may be compared to that
given by certain serums when employed as preventives. Thus, accord-
ing to the author's opinion, there may be a prophylactic and a curative
mammitis.

1 Revista de Ciencias Medicas de Barcelona; New York and Philadelphia Medical
Journal, August 29, 1903.

264 OBSTETRICS.

Acute General Staphylococcus Infection through the Puerperal
Breast. It is generally agreed that all serious disorders of the breast
during the puerperal period are the result of microbic invasion, either
through the duets or more frequently through cracks and abrasions of
the nipples or areola. \V. 1'. Manton1 urges the responsibility resting
upon the obstetrician to properly supervise the management of the
breasts, and deprecates the frequent carelessness in this respect. The
functional activity of the breasts and their constant exposure to the
traumatism of the nursing infant render them peculiarly susceptible to
infection, and mothers and nurses are often careless about handling
the breasts and nipples with unclean fingers. Moreover, the milk
itself may contain staphylococci, or other micro-organisms may be
excreted by the breasts when pathogenic germs have gained entrance
into the blood from diseased organs. The author is strongly opposed
to the routine use of massage of the breasts for cases of engorgement.
He believes that distention can be better treated by other means
without the dangers of traumatism and subsequent formation of an
abscess, which may lead to general septic infection, and reports a case
of general staphylococcus infection following bilateral breast abscess.

Discussing this paper Bacon excluded massage in all cases of infec-
tion of the breast and believed that massage properly performed was
of great value in simple engorgement. In practising massage of the
breast, rubbing toward the nipple, as usually done, is an error. The
movement should begin outside the breast and aim to empty the vessels
leading to the axillre and the subclavian veins and lymphatics. Mas-
sage of the breasts in the presence of infection of and through the
lymphatics is certainly dangerous, but one cannot always define such
cases, although a gradual rise in temperature, a rapid pulse, redness
and puffiness of skin, the absence of a "cake" and of marked tenderness,
and the presence of a sore or fissured nipple suggest lymphatic infec-
tion. In such cases I have always avoided massage and directed to
have the breast put at rest, covered with an evaporating lotion over
which is placed an ice-coil or bag. For the cases of simple engorge-
ment with a swollen and very painful lobule massage skilfully applied
cannot be discarded.

Pyelonephrosis in Pregnancy and the Puerperium. Kendirdjy2
believes that pyelonephrosis follows compression of the ureters by the
pregnant uterus, causing dilatation of the ureter and kidney. Such
dilatation was found in 25 of 34 cases (Olshausen) ; 8 in 32 (Lohlein) ;
35 in 130 (Pollak). Subsequent infection may be ascending from the

1 Journal of the American Medical Association, 1903, vol. xli.

2 Gazette des Hopitaux, 1904, No. 41-44.

PUERPERAL INFECTION. 265

bladder, or, more commonly, since the majority of cases show no cys-
titis, from organisms circulating in the blood and passing through the
renal epithelium. In some cases, first occurring after labor, the infec-
tion of bruised and injured ureters following difficult delivery is the
important cause. The symptoms, which may appear suddenly, are
usually gradual in onset, and commonly occur during the last four
months of pregnancy. They are pain, renal crises, albuminuria more
than the pus accounts for, and in some cases signs of nephritis. The
general health may not be seriously impaired, or there may be pro-
found prostration, with high fever and rigors. In most cases recovery
follows parturition spontaneously, although some cases may require
surgical treatment. Cystitis frequently is absent, although irritability
of the bladder is usual, and before resorting to surgical treatment the
ureters should be catheterized.

Pyelonephritis in the puerperium may not be accompanied by fever,
especially when there has not been a febrile reaction during pregnancy.
When the latter has been observed shortly before delivery, it continues
during the puerperium, and may be differentiated from puerperal
infection by the low morning temperature, the wide fluctuations in
temperature, the character of the pulse, and the good general condition
of the patient. It is important to differentiate the two conditions in
order to avoid unnecessary intrauterine treatment. When the suppu-
ration persists after the puerperium the prognosis is that of pyelo-
nephritis under other conditions. In 62 cases there were 2 deaths.
Expectant treatment should usually be followed, since spontaneous
recovery is the rule after evacuation of the uterus. Milk diet, urinary
antiseptics, and large quantities of water will usually restore the
kidney. The necessity for terminating pregnancy or for surgical treat-
ment during pregnancy is not universally recognized. Induction of
premature labor or abortion has been opposed by Vinay and advocated
by Wyrnan. It has been my practice to decide this question by the
severity of the case and the results obtained from expectant treatment,
and I agree with Kendirdjy that in a serious case, before viability of
the child, surgical treatment is to be employed, with the expectation
that the relief following will permit the pregnancy to go to term.
After viability of the child, if the case is a serious one, then induction
of premature labor at a period as near full term as the case will permit
will be indicated, and surgical treatment is to be reserved for the cases
that refuse to heal after the obstruction to the ureter has been removed
by the diminution of the size of the womb following delivery. I have
lost faith in the value of catheterizing the ureters and treating the
ureter and pelvis of the kidney by injections through the catheter. It
is tedious, exceedingly disagreeable to the patient, and often inefficient,

266 OBSTETRICS.

and it has been my practice to at once resort to an incision and drain-
age through the loin in the serious eases that fail to improve under
expectant treatment.

Harberlin1 reports eight eases, and also emphasizes the importance
of mechanical pressure as an etiological factor, adducing as evidence
the facts that all the symptoms quickly disappear if the organs of the
true pelvis arc relieved of the pressure of the fetal skull, and that tin
history shows an absence of preceding inflammation of the urinary
tract. He believes in expectant treatment and that there is no indi-
cation for the induction of premature labor. If the pressure is very
great he advises that the child's head be lifted by a pessary, or bv a
suitable position in bed the symptoms may be relieved. Salol and
urotropin, the free use of water and morphine for the painful crises are
recommended.

Puerperal Haematoma. Fatal cases of hematoma are rare, since
the antiseptic treatment of this complication has been applied, and
deaths from hemorrhage or gangrene and sepsis are uncommon. Em-
bolism sometimes occurs, and is the cause of a fatal termination, as in
a case reported by Dorland.2 The patient, aged twenty-eight years,
suffered from a long-standing cardiac affection (mitral regurgitation).
She developed symptoms of kidney disease during her pregnancy, and
spontaneous delivery of a stillborn child occurred at the eighth month.
Forty-eight hours after her labor she began to bleed from the uterus,
and a small hematoma appeared on the right labium majorum, which
gradually increased in size. Pain in the right ovarian region and marked
tympanites, with slight temperature and pulse elevation, soon followed.
The following day the dark swelling on the labium had extended into
the vagina and back on the perineum to the rectum. The same day
the symptoms of embolism occurred, followed by limited movements of
the entire right side. The mind was clear, there were no signs of
facial paralysis, nor did the tongue deviate to the side of the mouth.
Paralysis of the right side became complete, and death followed
seventy-six hours after the birth of the child. Post-mortem examina-
tion of the haematoma showed that the tumor began at the upper right
side of the vagina and extended outward and downward to lose itself
below in the pelvic structures. The clot was found to extend from
the pelvic ramus back to the coccyx and out toward the obturator fora-
men. The clot was thoroughly encapsulated, and measured 7 x 3§ x 1
inch.

The associated cardiac and renal disease in this case explain the

1 Miinchener med. Wochenschrift, 1904, li., 198, No. 5.

2 American Journal of Obstetrics, June, 1904.

PATHOLOGY OF THE NEWBORN INFANT. 267

occurrence of embolism, and structural changes in the bloodvessel walls
doubtless predisposed the patient to the formation of the haematoma.
Whether the embolism was dependent upon the formation of the hema-
toma is a question. In all probability it resulted from the changes
induced by the cardiac and kidney diseases.

PATHOLOGY OF THE NEWBORN INFANT.

Injuries to the Child's Head during Delivery. Depressions of
the skull during delivery are produced, as a rule, in contracted pelves
by pressure of the promontory, says Robert Jardine.1 As a rule, the
frontal bone has been the one affected, but the parietal also was de-
pressed in some cases after breech delivery. Fracture may occur, and
yet there may be no evident depression. Two cases which occurred
under his own observation are reported. The first was a difficult for-
ceps delivery in a contracted pelvis. Though there had been consider-
able pressure over the frontal bone, there was no depression, and the
child seemed all right. It became restless in a few hours, gradually
grew worse, and died seventeen hours after birth. Autopsy revealed
a fracture of the left frontal bone involving the orbital plate, and the
left frontal lobe of the brain was lacerated. In the second case the
child showed no signs of respiration after birth, but the heart beat
for five minutes. Autopsy revealed the right parietal bone over-
riding the left, slight hemorrhages over the frontal bones, and a
complete fissured fracture in the lower part of the left frontal bone a
half-inch above the orbital plate, running out horizontally to the coronal
suture.

A case is reported in which a rickety woman with a diagonal con-
jugate of four inches was delivered by forceps. As the frontal bone
passed the promontory a dull thud was heard ; there was depression of
the frontal bone, but apparently no inconvenience to the child. At-
tempts to raise it by firm pressure failed. When twelve days old an
incision was made through the back part of the frontal bone a quarter
of an inch in front of the suture ; as the dura mater is always adherent
at the sutures, an elevator was passed between the dura mater and the
bone, and the bone elevated. As the elevator was passed blood-stained
serum escaped. The child recovered, but there is still a slight flatten-
ing of the bone, which is gradually rising. Had the operation been
done at birth the arch would probably have been completely restored.
Munro Kerr says that a depression of the skull may be raised by apply-

Journal of Obstetrics and Gynecology, British Empire, June, 1903.

•^r,* OBSTETRICS.

ing pressure to the head anteroposterior^ in an oblique diameter at righl
angles to the depression, and this simple procedure should be first tried.
[f unsuccessful, cut down through the bone and raise the depression at
once. Cortical or meningeal hemorrhages, traumatic keratitis, and
hemorrhage into the optic nerve, retina, or anterior chamber of the eye
may occur. Subjunctival hemorrhages arc common, even in normal
labor. Cortical and meningeal hemorrhages are liable to cause death,
and, even if the child survives, there is grave risk of permanent brain
injury.

Ocular Injuries during Labor. Thomson and Buchanan1 report
their observations of this class of injuries in the wards of the Glasgow
Maternity Hospital. Traumatisms of the eyelids with resultant oedema
and ecchymosis are often seen. Sometimes in unassisted labors retinal
and choroidal hemorrhages occur. The chief injuries from the pressure
of the blades of the forceps are excoriations, oedema, fracture of the
orbit, corneal affections, hyphsemia, paralysis of the ocular and lid mus-
cles, retinal and retrobulbar hemorrhage, optic atrophy, cataract, dis-
location of the lens, exophthalmos, and evulsion of the eyeball. They
believe that almost any injury to the internal structures of the eyeball
is possible in cases of contracted pelves requiring difficult forceps de-
livery. They also call attention to a peculiar form of traumatic kera-
titis which, from microscopic examination, they believe is due to vertical
rupture of the posterior elastic corneal lamina, and which varies in
severity from a transient haziness to a more or less permanent opacity.
Bouchet has observed fracture of the frontal bone and exophthalmos,
followed by recovery without paralysis or convulsions. In a case of
exophthalmos and hyphemia following the use of forceps in a prim-
ipara, reported by Schroeder, an autopsy revealed hemorrhage into the
orbit (which explained the exophthalmos) and detachment of the dura
mater from extravasation of blood. Stanheim has observed oedema
and cicatricial entropion following forceps delivery. These evil results
of forceps are rare and must occur in unskilled hands, for with ordinary
skill permanent ocular injury is very infrequent.

Birth Palsies. In a review of histories in nervous clinics it was
found by Bochroch2 that birth palsies were more frequent in the prac-
tice of the general practitioner than in institutions attended by the
obstetrician. The reasons are probably the character of the people
among whom many physicians practice, and the absence of any oppor-
tunity or facility for the exercise of skill. In such lesions of the brain

1 Transactions of the Ophthalmological Society of Great Britain, 1903 ; American
Med., April, 1904.

2 New York and Philadelphia Medical Journal, September 19, 1903.

PATHOLOGY OF THE NEWBORN INFANT. 269

as produce hemiplegias, microcephaly, porencephaly, and hydroceph-
alus, careful investigation revealed that the forceps was more frequently
used too late than too soon, and the author was convinced that pro-
longed pressure, such as occurs in primipane, is more often the cause of
such lesions than unskilful use of the forceps. The lesion which
causes a cerebral hemiplegia or diplegia is probably one of hemorrhage
due to laceration of the veins of the pia mater as they enter the longi-
tudinal sinus, or from other sources. Thus it would seem to be a justi-
fiable procedure in such cases to make an opening upon either parietal
region and allow the blood to escape, or wash it out with normal salt
solution ; by some such means much subsequent mischief could prob-
ably be averted. Erb's paralysis or brachial palsy is characteristic ;
the affected arm falls motionless to the side, being turned in and ex-
tended. Flexion of the forearm and raising of the arm is impossible,
while the hand and finger movements are retained. This injury results
from excessive traction or pressure upon the shoulder, and is probably
related to the outer cord of the brachial plexus. The following con-
clusions are the results of experiments by Carter and Fieux : 1. In a
spontaneous labor one should not be in too great haste (in making
traction upon the head) to deliver the trunk. The latter should be left
to nature, or assisted by means of expression. Only in necessity should
traction be made upon the head, and then the head should be flexed
laterally only so much as is absolutely necessary to conform to the needs
of the case. In case it be necessary to hook the axilla, too great trac-
tion should not be made. 2. During extraction by means of forceps
expression should be used as an assisting factor, presupposing that the
shoulders meet with an obstacle at the entrance of the pelvis. One
should remember Walcher's posture and bring the forceps not far out-
side of the direction of the axis of the body. Dauger only arises when
there is a deviation from thirty degrees, but a slight pendulum move-
ment is not prohibited. 3. During extraction by means of the feet the
arms should be quickly attended to, in case they are interfering, by
Mauriceau's procedure — /. e., by placing the finger in the mouth of
the child and using the arm to assist in traction, resorting in grave
cases to expression and, if necessary, to Walcher's position. Should
the extraction of the head offer considerable difficulty, this may be
considered as an indication for the application of forceps to the after-
coming head, in order to avoid stretching the nerves of the axilla.
The treatment of brachial palsies may be both surgical and medical.
In serious cases surgical interference should be considered. Tn cases
where nerves are torn they might be sutured. Massage and electricity
are the medical means employed ; the arm should be supported in a
sling or Velpeau bandage.

270 OBSTETRICS.

Brachial Birth Palsy and Irs Surgical Treatment. Clark
and Taylor' concluded that: 1. The most important etiological factor
in the production of brachial birth palsy is a direct or indirect tension
of the nerve trunk, which causes rupture of nerve fibres. 2. An ex-
planation of the persistence of the palsy was clearly based upon the
pathological findings, which consisted of a destruction of the axis
cylinder by rupture of the nerve fibres and formation of an over-
growth of connective tissue between the torn nerve ends, through
which the nerve fibres cannot regenerate. 3. The nature of the lesion
in all typical severe cases demands excision of the damaged nerves
and suture of the good ends at the earliest possible moment, as in the
treatment of peripheral nerve injuries elsewhere. 4. From the sur-
gical viewpoint the desirable time for this interference was not yet
determined. It would, however, seem to be much later than two or
three months after birth, as Kennedy advised. 5. The present medi-
cal treatment, consisting of an application of massage, electricity, and
systematized muscle movements, should follow the surgical interference.
0. The prevention of this serious lesion of the brachial plexus rests
with the obstetrician, who should not stretch the child's neck in the
process of delivery.

Taylor,2 in discussing this topic, said that the usual causes stated in
the books are pressure upon the clavicle during birth, hyperextension
of the arm, pressure of the forceps, pressure of the fingers, etc., but
that in the later literature tension is given the most prominent place
in etiology. He has experimented on stillborn children, placing them
in attitudes assumed during delivery. Pushing back the clavicle he
failed to get enough pressure to cause tension of the nerves. Other
maneeuvres were followed out, and he finally found that anything
which depressed the shoulders and increased the distance between the
shoulder and the neck caused greater tension of the nerves in question.
First the fifth and sixth nerves would give way, then further pulling
would cause a similar damage to the seventh nerve. He was con-
vinced that tension was the important factor, and prophylaxis consisted
in not pulling the head away from the shoulder when the latter was
fixed, or not to pull on the shoulder away from the head when that was
fixed. Sachs3 pointed out the fact that not all obstetrical palsies were
cases of Erb's palsy, because, he believed, there were many obstetrical
palsies that had nothing to do with the fifth and sixth cervical nerves ;
there were many instances in which traction upon the arm produced
luxations and subluxations, and the pressure of the head of the humerus

1 Medical News, July lfi, 1904.

- [bid. s [bid,

PA THOL 00 Y OF THE NE WE OEN INF A NT. 271

was at a point lower down than the fifth and sixth nerves. There-
fore, a word of caution was needed about one method of operating
being a cause for obstetrical palsies. Many of the cases do well under
a natural mode of recovery. Could one expect more from operation
than from the inherent recuperative powers of the nerves and muscles
themselves? When muscular atrophy and a great deal of wasting,
especially about the shoulder, were present no amount of suturing of
nerves or transplantation of their divided ends would bring about
satisfactory results. In carefully selected cases operation might be of
benefit. Much of the trouble was due to secondary changes in the
muscles and ligaments about the joints, and these must be overcome
before surgical treatment is undertaken. He believes the operation a
dangerous one ; aside from the hemorrhage and shock, the proximity of
the cervical portion of the spinal cord adds a distinct danger. Several
months of treatment by electricity, massage, and intelligent muscle
exercise should always be employed before operation is resorted to,
since I have observed several cases completely cured following these
means, assisted by nature's recuperative power. If one could deter-
mine positively that the nerves had been torn and their ends separated,
then an early operation, not later than the fourth or fifth month,
would be justifiable, but the fact of such separation cannot always be
positively determined.

Oxygen in Asphyxia Neonatorum. Oxygen has proven especially
efficacious in these cases in the hands of W. Zangmeister. l It is his
practice to pass a small flexible catheter into the trachea of the child.
The catheter is connected to a rubber tube with a ball pump, the other
end of which is connected with an oxygen cylinder. The lungs are
slowly and gently inflated with oxygen by pressing the ball pump
with one hand, and deflated by pressing gently upon the thorax with
the other hand. The gas escapes between the catheter and the tracheal
walls, and it must be observed that the catheter used is not too large
to permit of this escape taking place easily. Artificial respiration is
thus performed by compressing the ball and chest alternately. The
skin soon becomes a bright red, indicating the relieving of the car-
bonic-acid narcosis. Following the application of stimulants, recovery
soon ensues.

The Etiology of Ophthalmia Neonatorum. Since bacteriological
examinations of the discharge in purulent ophthalmia of the newborn
infant have become so frequent, we are learning that gonorrhoea is not
the only important cause of this disease. Under this disease a series
of infections must be grouped, and Morax2 states that gonorrhoea is

1 Zentralbl. f. Gyn., September 2f>, 1903.

2 Annnles de Gynec. etd'ObstSt., August, 1903.

272 OBSTETRICS.

the canst' in not more than half the cases. The diagnosis of non -gonor-
rheal ophthalmia is determined by finding the gonococcus absent and
other or qo micro-organisms present. The pneumococcus, the strepto-
coccus, or the bacillus of Weeks have been found. When no micro-
organism is discovered, Morax thinks the infection may be due to a
micro-organism with which we are not familiar. Clinically, non-gonor-
rhceal ophthalmias arc variable in their onset, most of them occurring
after the seventh day ; the secretion is less abundant, is usually
catarrhal, and docs not tend to accumulate in the conjunctival sacs so
abundantly as in gonorrheal cases ; and grave lesions of the eyes are
uncommon. I have recently observed a ease with all the clinical
symptoms of virulent gonorrheal infection, but the pneumococcus was
demonstrated to be the infecting agent. The treatment in the latter
case was the same as for a gonorrheal infection — half-hour irrigations
with salt solution, and 20 per cent, argyrol solution, one drop every
two to four hours; atropine and hot or cold compresses, according
to the condition of the cornea. The nutrition of the child was also
given close attention.

Infections of the Newborn Infant. The question of the infections
of the newborn infant has been more or less overshadowed by the
relatively more important one which concerns itself with the same
condition in the mother. The fact that children died shortly after
birth with symptoms more or less obscure, and the lack of close study
of such cases, led to the adoption of various names; they are really
in certain instances nothing more than an attempt to explain the mor-
tality. Such names, for instance, as " meleena neonatorum," " hem-
orrhagic disease of the newborn," "Buhl's disease," " "Winckel's dis-
ease," " haemophilia of the newborn," simply serve as pegs upon which
to hang the case, and do not at all enlighten us as to the actual
causative pathological conditions.

If the opinion of a number of investigators be substantiated by
future work it will be found that many of the deaths now attributed
to the unknown pathological entities above mentioned will resolve
themselves simply into cases of septic infection, the nature and severity
of the symptoms depending upon the character and virulence of the
infecting organism versus the degree of individual resistance. In a
series of six cases reported by Hamill and Nicholson1 there was a
different micro-organism isolated in each of them, namely, the bacillus
pyocyaneus, the bacillus lactis aerogenes, the colon bacillus, the
staphylococcus aureus, the bacillus eoli immobilis, and a strepto-
coccus. In the literature which has already accumulated, however,

1 Archives of Pediatrics, September, 1903.

PATHOLOGY OF THE NEWBORN INFANT. 273

instances are reported in which the causal factor has been infection by
the pneumococcus, Pfeiffer's bacillus, the bacillus of Babes, the bacillus
hemorrhagica of Kolb, the bacillus of Gaertner, and the encapsulated
bacillus of Dungern, while among the recorded cases the greater
number have been shown to be infectious by either the streptococcus,
staphylococcus, or the bacillus coli communis. The above reference
to reported cases shows that no one group can be held accountable,
and this may be taken as indicating that the primal cause is to be found
in faulty aseptic technique in its application to the child.

If the opinions expressed above regarding the etiology are found
to be correct we are still somewhat at a loss to explain definitely the
method of inoculation. Hamill and Nicholson believed, as a result of
their study of the cases reported, as well as of another series of nine
cases, that in many instances it was the result of lack of cleanliness on
the part of the nurse, as their cases developed in various wards and
as there was no uniformity in the germs isolated. Moreover, the
same nurse was found to have cared for different children affected. It
is to be remembered that these infections are decidedly rare in private
practice, and so it is well to bear in mind the possibility of the occur-
rence of air infection as a rare possibility. The mother's milk may
also be the causative factor, as in apparently normal breasts both
staphylococci and streptococci have been found, but this is probably
a very rare etiological factor.

The symptoms presented by these infections are as follows : fever,
usually early in the course of the illness, and varying from a slight
degree to actual hyperpyrexia; diarrhcea, with greenish mucus con-
taining stools, is also present in the majority of cases ; icterus some-
times of a very intense grade ; skin eruptions of almost every descrip-
tion have been met with ; apathy, emaciation, and refusal to nurse
are always present ; hemorrhage of varying degree, from one or
several of the following localities — i. e., the skin, navel or cord, eyes,
ears, nose, mouth, vagina, bladder, stomach, or bowels — usually
manifests itself at some period of the disease, and nervous phenomena,
consisting of convulsions, retraction of the head, nystagmus, tetanic
and tonic spasms, etc., occur. Cyanosis, with rapid, labored, and
irregular respirations usually toxic in origin, may occur early, but
more frequently later in the disease.

The statements just made with regard to the bacteriology and symp-
tomatology should cause every febrile movement in the newborn child
to be viewed with suspicion until its real meaning is proven. If with
fever there is also noted enteritis, a skin eruption, and rapid emaciation,
the condition may be considered infectious as far as treatment is con-
cerned ; while if to the above symptom-complex there is added hemor-

18

•j7i OBSTETRICS.

rhage, nervous phenomena, cyanosis, and rapid, irregular respiration
the picture is complete. It is well to bear in mind that in several of
the eases examined a diagnosis of inspiration pneumonia had been made
which was not confirmed at the autopsy.

As t<> prognosis, it can only he stated to he distinctly had, since
treatment is, as a rule, of no value in even mitigating the severity of
the symptoms. Lee,1 in his review of Aht's article in the volume
OD Obstetrics in the Practical Medical Series for 1904, gives an
account of a case recently seen by him in which hemorrhage was a
symptom. His treatment included the use of calcium chloride, a 1
per cent, solution of gelatin, and adrenalin solution (1 : 1000) in four-
drop doses every three hours. He is in doubt as to whether his treat-
ment did or did not influence the favorable outcome in this case, an
attitude of mind which everyone who has ever dealt with these cases
will share with him.

As the practical lesson to be gained from these studies, it should be
impressed upon those having charge of young infants that they are
extremely susceptible to infection, and that the greatest care should be
exercised in order to prevent its occurrence by the exercise of as much
care in the preparation of the hands of the nurse before cleansing the
eyes or mouth or dressing the cord of the child as she would exercise
in caring for the breasts or genitalia of the mother.

1 Journal of the American Medical Association, January 31, 1903.

INDEX.

ABDOMINAL muscles, paralysis of,
166
pain in pleurisy, 36
Abortion and pregnancy late in life, 194
Abscess, cerebral, 152
of lung, 52
of uterus, 261

during puerperium, 261
Accessories palsy in tabes, 155
Achilles jerk and frqnt-tap, 184
Acne, 101
Acromegaly, 182
Acroparesthesia, 180
Actinolite, 103
Actinotherapy, 102

Administrative control of tuberculosis, 18
Adrenalin for asthma, 56
for tuberculosis, 32
in dermatoses, 135
in heart disease, 98
intrapleural injections of, 37
Air embolism, 66
liquefied, 60

open, in treatment of bronchopneu-
monia, 49
Albuminuria in eclampsia, 205
Alcohol applications for pleurisy, 38
Alimentary dechlorination for oedema, 73
Allorhythmia, 92
Altitude, contraindications for, 26

in heart disease, 97
Ammonium hippurate, 70
Amputation, spontaneous, of cervix in

labor, 237
Amyotrophic lateral sclerosis, 162
Analgesia, obstetric, 238
Aneurysm, 61

Brazilian method lor, ti2
diagnosis of, 61
electric treat ment of, 62
posit ion of heart in, 61
treat ment of, 61
Angina pectoris, 89

( Jolbeck's theory of, 89
biliary, 00

in mitral stenosis, SO
infective, 89
Angioma, 104
Animals, syphilis in, 13!)
Anthracosis, 5(1
Antiquity of syphilis, 138
Antiseptics in empyema, 40
Antistreptococcus serum, 00, 253

in rheumal ism, 00
\orta. 60

Aorta, aneurysm of, 61

congenital stenosis of, (il)

inflammation of, 61

rupture of, 61
Aortic diastolic murmurs, 81

valves, 80
Aortitis, acute, 61

rheumatic, 61
Appendicitis, 36

Arctic treatment for tuberculosis, 26
Arhythmia, 91

clinical analysis of, 92

continuous, 91

nervous, 93

traumatic, 91
Arrested tuberculosis, 23
Arsenical neuritis, 173
Arterial hypermyotrophy, 62

hypertension, 68

hypotension, 69

pressure, 68, 69

system, congenital stenosis of, 62
Arteries, calcification of, 62
Arteriosclerosis, 63, 94

and infectious diseases, 63

juvenile, 63

nature of, 63

Trunecek's serum for, (if
Aseptic air, pleural fluid replaced by, 3(1
Asphyxia neonatorum, oxygen in, 271
Asthma, 55

adrenalin for, 56

etiology of. 55

false, of gastric origin, 55

lobelia for, 55

methyatropine bromide for, 56

pathology for, 55

periodicity of, 55

treat ment of, 55

by the direct route, 56

Asylums for tuberculosis, 32

Ataxia, 187

At heroma, experimental, 62

Atrophy, muscular, 163

Auricle, rupture of, NX
Auscultation, immediate, 45

rod, 46
Auto-serum therapy, 37

BACILLI Of syphilis, 13!)
■ Baqjllophobia, 1!)

Bacillus acnes, 101

of chancroid, 100
Bacterial treatment of tuberculosis, 27

2 7 (5

INDEX.

Bacteriology in puerperal Infection, 246

Baldness, 105

Barber-shop hygiene, 106

Basedow's disease. See Graves' disease,

Bed-Punkah for tuberculosis, 28

Beneke I reatmenl . '.'7

Biliary angina pectoris, 90

Birth palsies, 268

l>al-\ . brachial, 270

surgical I real menl <>f. 270
Blood in tuberculosis, 33

pressure, 07

capillary. 71
clinical aspects of, 68
t herapeutic aspects of, 69
Bloodvessels, 60

diseases of, 1 7

effecl of typhoid fever on, 86
Boils, 120
Bossi's dilator, 216
Brachial birth palsy, 270

surgical treatmenl of, 270
Bradycardia, 90

etiology of, 90
Hraiii, cysts of, 151

diseases of, 149

gliosarcoma of, 150

tumor, 149

optic symptoms of, 152
Brazilian method for aneurysm, 62
Breast, staphylococcus infection through,

204
Breech presentation, 221
dangers of, 221
treatment of, 221
Bronchiectasis, 51

and empyema. 51

etiology of, 51

in tuberculosis, 51
Bronchiolitis, fibrous obliteration, 50
Bronchitis, .50

capillary, 48

chronic, treatment of, 50

diphtheritic, 50

fetid, 51
Bronchopneumonia, 48

and pertussis, 19

etiology of, 49

open air for, 49

treatment of, 49
Bronchorrhcea, 50
Brown-Sequard paralysis, 165
Bulbar palsy following diphtheria, 154
Burns. 107

carbolic acid, 108

CESAREAN section, vaginal, 229
for eclampsia, 212
< 'a i ->o ii disease, 66
Calcification of arteries, 62
Campaign against tuberculosis, 17
Capillary blood pressure, 71
Carbolic acid burns, 108
Carbon dioxide for tuberculosis, 31
Carbonate of creosote, ">7
Cardiac disease, mental symptoms in, 82.
See Heart disease.

Cardiac, inflammation, predisposition to,
83
reflex, 78
Cardiolysis, 73

( ardioptosis, 77
Cardiopulmonary murmurs, 81

respiratory murmurs, M

splanchnic phenomenon, 78
( 'aseopurulent nicdiast inopericardit is, 74
Cerebellar tumor, 151
( lerebral abscess, 152
Cervix, artificial dilatation of, 217

fibroid of, obstructing labor, 202

Laceration of, 219

repair of, 219

spontaneous amputation of, in labor,
237
Chancroid, 109

bacillus of, 109

Of eyelid, 109
( 'haulmoogra oil, 124
Chest, cold compresses to, 59

examination of upper, 47

position of, in dyspnoea, 43
Chloroform syncope, 99
Chorea, 179

and Graves' disease, 179

in pregnancy, 194
Chromidrosis, 1 10

Cinnamate of sodium for tuberculosis, 31
Circulation lymph, 70

peripheral, 70
Circumscribed oedema, acute, 72
Climate, altitude, contraindications to, 26

sea, contraindications to, 26
Climatic treatment of tuberculosis, 24. 25
Colbeck's theory of angina, SO
Colds, common, 54
Colon, distention of, 77
Common colds, 54
Compress, cold, to chest, 59
Conception, diagnosis of, 189
Congenital heart disease, 73

mitral stenosis, 84

stenosis of arterial system, 62
Contraindications to altitude, 20

to sea, 20
Corpuscular elements, 72
Coryza, iodine, 54
Cough, treatment of, 57
( toughs, nervous, 57

preventable, 57
Crede's method, dangers of, 239
Creosote carbonate, 57

treatment of tuberculosis, 27
Cubicle, Stoker's, for tuberculosis, 29
Curability of syphilis, 142
Cyanosis, chronic, 83
Cyst, spinal, 160
Cysts of brain, 151
Cytodiagnosis in tabes, 156
Cytological diagnosis of pleurisy, 34

DECHLORIDATION, alimentary, for
oedema, 73
Delivery, injury to child's head during,
207

INDEX.

277

Dermatitis, bullous, 1 10

radio-, 133

venenata, 111
Dermatology, 101

adrenalin in, 135

radium in, 131
Diagnosis of tuberculosis, 32
early, 33

physical, 44
Diaphragmatic pleurisy, 35
Diastolic aortic murmurs, 81

murmurs without lesion of aortic
valves, 80
Diet in heart disease, 98
Digitalis, 98
Dilatation, artificial, of cervix, 217

mechanism of cardiac, 84
Diphtheria, bulbar palsy after, 154
Diphtheritic bronchitis, 50
Diseases of bloodvessels, 17

of brain, 149

of heart, 17

of lungs, 17, 48

of nerves, 170

of nervous system, 149

of spinal cord, 155

of thorax, 17
Dispensary for tuberculosis, 21, 22
Disseminated sclerosis, 166
Distention of colon, 77
Divers' palsy, 67
Double empyema, 39
Drainage for empyema, 39
Dropsy, 72

acute circumscribed, 72

and mitral stenosis, 72

treatment of, 73

unexplained, 72
Duhrssen's operation, 229
Dulness, manubrial, 48
Dust diseases of the lungs, 49
Dysentery, cardiac complications of,

86
Dyspnoea, position of chest in, 43

ECLAMPSIA, 203
albuminuria in, 205

diet in, 203

experimental work on, 203
metabolism in, 203
morphine in, 207
surgical treatment of, 211
thyroid extract in, 209
vaginal Ca-sarean section lor, 212
vascular system in, 207
veratrum viride in, 208
Eczema, 111

radiotherapy for, 1 1 3
Effusion, pleural, 34

cytologieal diagnosis of, 34

eosinophile, 34

serofibrinous, 34

syphilitic, 34

treatment, of, 36

tuberculous, 35

typhoid, 34

upper edge of, 35

Electric treatment of aneurysm, 62
Embolism, air, 66

fat, 66
Emphysema, 53

glass-blowers', 53

in epilepsy, 178

surgical, 53
Empyema, 38

and bronchiectasis, 51

and pyopneumopericardium, 74

antiseptics for, 40

boiled-water irrigation for, 40

double, 39

drainage for, 39

Lile's drain for, 39

pulsating, 38

sterilized air for, 40

treatment of, by incision, 38
Endocarditis, 85

and paratyphoid, 85

and rheumatism, 86

and typhoid, 85

gonococcus, 85

Lee's treatment of, 99

micrococcus rheumaticus, 86

pneumococcus, 75

rheumatic, infective nature of 86

streptococcus, 86

traumatic, 76

ulcerative, 85
Eosinophile pleural effusion, 34
Epilepsy, 176

changes in hair in, 177

emphysema in, 178

.lacksonian, 177

tachycardia in, 96
Epithelioma, 115
Erb's paralysis, 269
Eruptions, feigned, 115
Erysipelas, 113
Ervthromelalgia, 183
Etiology of tuberculosis, 32
Exercise in hysteria, 178

in tuberculosis, 27
Exophthalmic goitre. See Graves' dis-
ease.
Exploratory puncture, death or syncope

from, 36
Extrauterine pregnancy, 196

sac, foetus retained in, 197
Eyelid, chancroid of, 109

FACIAL palsy, 170
anastomosis of nerves lor, 171

bilateral, 171

contractions in, 171

from fright, 172
Fat embolism, tit)
Feigned eruptions, 115
Fetal heart murmur, 82
Fetid bronchitis, 51

Fever, puerperal. See Puerperal infec-
tion.
Fibroid of cervix obstructing labor, 202
Fibroids complicating pregnancy, 198
Fibrous obliferative bronchiolitis, 50
Fistula, tracheo-oesophageal, 57

278

INDEX.

Float ing liver, 78

Foetus retained in extrauterine sac, L97
Forceps in occipitoposterior position, 22l>
Formaldehyde for tuberculosis, -!l
Formalin in puerperal infection, -I I
Fracture of vertebra, L69
Front-tap and Achilles jerk, is I
Furunculosis, 120

GANGRENE of lung, 52
( larlic for tuberculosis, 32
Gasserian ganglion operations, 173

condition oi taste after remov
ing, 17 1
Gastric crisis in tabes, 155
origin of false asthma, 55
ulcer, perforation of heart by, 89
( ielatin tetanus, 61
Giantism, 183

Gigli's method of pubiotomy, 228
Glass-blowers' emphysema, 53
( rliosarcoma of brain, 150
< Hove, rubber, 242, 2 15
Gonococcus endocarditis, 85
Gonorrhoea during pregnancy, 2.">N

puerperium, 258
Graves' disease, 180
and chorea, 179
Gravid uterus, incarceration of, 193
( luinnia, ulcerated, 141

HjEMATIDROSIS, 110
Haematoma, puerperal, 266
Hair, changes in, in epilepsy, 177
Head, injuries to, during delivery, 267

treatment of after-coming, 221
Heart, 75

abnormal movements of, 76
complications of dysentery, 86
disease, 17

abdominal massage in, 96

adrenalin in, 98

altitude in, 97

congenital, 83

diet in, 98

etiology of, 84

frequency of, 82

functional 94

mental symptoms in, 82

pathology of, 88

prevention of, 96

saline inject ions for, 100

treatment of, 96
displacements of, 76
effect of typhoid fever on, 86
examination of, 75
failure, 98

functional fitness of, 78, 79
hypertrophy, compensatory, 85
inflammations, predisposition to, S3
irregularity of, 91
massage, 99

mechanism of dilatation of, 84
murmur, fetal, 82
murmurs, value of, 70
normal movements of, 7.">

Heart, perforation of , by gastric ulcer, so
posii ion of, in aneurysm, 01

rhyt Inn, almorinalil ies of, 90

rupture of, SS

sound, second, sit
si imulants, 98
syphilis, 86
Hemiplegia, 153

asymmetry of respiratory move-
ments in, 13
crossed, with paralysis of ocular
movements, I ">.'•!
Hemisystole, '.»:;
Hemorrhage into cavity of cord, 10 I

post-partum, 240
Hereditary mitral disease, 83
Hiccough, treatment of, 58
High-frequency currents in tuberculosis,

30
Hirsuties, 121

Home treatment of tuberculosis, 21
Hydatids, pulmonary, 53
Hygiene, barber-shop, 100
Hygienic treatment of tuberculosis, 27
Hyperchloridation, 70
Hvperchloruria in tuberculous pleurisy,

'35
Hyperemesis gravidarum, 192

intoxication theory of, 192
Hyperglobulia with chronic cyanosis, S3
Hypermyotrophy, arterial, 62
H vpertrophic pulmonary oste< >a rt 1 1 ropa-

thy, 52
Hypertrophy of heart, compensatory, 85

in syringomyelia, 165
Hypochloridation treatment, 54
Hvpoglossus paralysis, 172
Hvsterectomy for puerperal infection,

"254-258
Hysteria, respiratory exercises for, 178

TCHTHYOL, 57

J- for tuberculosis, 31

Immediate auscultation, 45

Incarceration of retroflexed gravid uterus,
193

Individual prevention of tuberculosis, 20

Induction of premature labor, 224

Infant, newborn, infections of, 272-27 1
pathology of, 267

Infantilism, L81

Infections of newborn infant, 272-274
puerperal, 242

bacteriology of, 246, 250, 253
formalin solution for, 244
gonococcus a cause of, 258
hysterectomy for, 254, 258
iodine in, 244, 246
method of infection in, 251
prophylaxis of, 242
rubber gloves in, 242, 245
salt solution in, 245
statistics on, 250

Infectious diseases and arteriosclerosis, 63

Infective angina pectoris, 89

Injuries during labor, ocular, 26S
to child's head in delivery, 207

INDEX.

27!'

Injury to the spine, 1 07

[nsurance and syphilis, 1 lo

[ntercostal phonation phenomena, 48

Intermittent claudication, 64, 181
Lameness, 64, 181

Intoxication theory of hyperemesis gra-
vidarum, 192

[ntralarvngeal injections in tuberculosis,
30

Intrapleural injections of adrenalin, M<

1 1 1 1 rat racheaJ inject ions. 59

Intrinsic pulmonary motility, 11

Iodine coryza, 5 1

in puerperal infection, 244, 2 Hi

lodism prevented, 5 1

Iodoform for tuberculosis, 31

Irrigation of empyema with boiled water,
40

[sola! ion in tuberculosis, 18

Itching, 12G

JACKSONIAN epilepsy, 177
Jugular vein, thrombosis of, in tu-

K

berculosis, 3 1

^.TZENSTEIN'S method, 7!)
Keloid, 122

LACERATION of cervix, 219
repair of, 219

Labor, fibroid of cervix obstructing, 202
injuries to child's head during, 2(i7
management of third stage of, 239
ocular injuries during, 268
premature induction of, 224
spontaneous amputation of cervix
in, 237

Lacke's formula, 245

1 ,ameness, intermittent, LSI

Landry's paralysis, 166

Larynx, paralysis of, 155

Latent tuberculosis, 20

Lateral sclerosis, amyotrophic, 162
unilateral, 162

Laws of puerperal immunity, 2f>:-i

Lead, paralysis resembling, 172

Lee's treatment for endocarditis, !'!•

Leprosy, 123

chaulmoogra oil in, 121

Lichen planus, 1 25

Lichenin, 70

Lile's empyema drain. 39

Lime-dust inhalat ion, 50

Liquefied air, fit)

Liver, float ing, 78

I .olielia for'asthma, 55

Locomotor ataxia. See I al >e

Lung, abscess of, 52

disease, fcherapeul ics of, 57

dust diseases of, 49

gangrene of, 52

hydatid Of, 53

reflex, 42

Lungs, 11

spira-

LungS, diseases of, 1 7. I'.i

margins of, 42

oedema of, 7:i
Lupus erythematosus, L03, 12 1

vulgaris, 124
Lymph circulal ion, 70

MAGNESIUM dioxide 60
Malarial affections of the
tory tract , 53
Mammitis, 263

Management of third stage of labor, 239
Manubrial dulness, 48
Marmorek's serum for tuberculosis, 27

test for tuberculous fluids. :-!2
Massage, abdominal, in heart disease,
96
of heart, 99
Meat, raw, for tuberculosis, 28
Mechanism of dilatation of the heart, M
of occipitoposterior rotation, 222
of rupture of uterus, 232
Medicinal treatment of tuberculosis, 30
Meningitis, tuberculous, 150
Mental symptoms in heart disease, 82
Metabolism in eclampsia, 203
Methylatropine bromide, 56
Metritis dessicans puerperalis, 262
Micrococcus rheumaticus endocarditis

maligna, 86
Microsphygmia, 62
Milk leg, '262

raw, for tuberculosis, 28
Mitral murmur, intensity of, 80
pseudoinsufficiency, 84
stenosis, 73, 80

and oedema, 72
angina in, 89
congenital, 8 1
systolic murmurs, 80, 83
Morphine and scopolamine, 238

in eclampsia, 207
Multiple neuritis, 172
sclerosis, 166
stet hoscope, 46
Murmur, fetal heart . 82

vesicular, nature of, 45
pulmonary, SI
Murmurs, cardiorespiratory, 81
diastolic, 80, M
heart, value of, 70

late systolic mil ral, 80

mechanism of, 80

nut ral, intensity of, 80

presystolic, 80

venous, 82
Murphj 's t real ment of tetanus, 260
Muscles, abdominal, paralysis of, 166
Muscular atrophy, 163
Musical pulse recorder, 68
Myasthenia gravis, 1 •"> I

and pregnancy, V.i~>

Myelitis. 166

Myocardial change in rheumatism, 87
Myoclonus mult iplex, LS2
Myomectomy, 200

280

INDEX.

N\ 1J( !( ISIS, scopolamine and morphine,
238
Nattan-Larrier's tesl for tuberculous

fluids, 32
Natural cure of tuberculosis, 21
Nauheim treatment, 97
Nerve suturing, 173

Nerves, anastomosis of, in facial palsy. 171
diseases of, 1 70

\it\ mis arhythmia, 93

coughs, 57

system, diseases of, 1 19
Neurasthenia, 179

Neuritis, arsenical, 173

multiple, 172
Neuroses, cutaneous, 12(5
Newborn infant, infections of, 272-274

pathology of, 207
Nit rate of thorium, 29
Notification of tuberculosis, 18

OBSTETRIC analgesia, 238
surgery, 217
Obstetrics, 189

Occipitoposterior rotations, 222
forceps in, 223
Tarnier's principle in, 223
( >cular injuries during labor, 268
movements, paralysis of, 153
(Edema, 72

acute circumscribed, 72
and mitral stenosis, 72
pulmonary, 73
treatment of, 73
unexplained. 72
Open-air treatment of tuberculosis, 21,

22, 24
Ophthalmia neonatorum, etiology of, 271
Opium in eclampsia, 207
( iptic atrophy in tabes, 1.57
( Isteosensibility, 181
Oxygen in asphyxia neonatorum, 271
inhalation of, 59
perflation. 40

PAIN, visceral, 69
Palsies, birth, 268
Palsy, accessories, in tabes, 155
brachial birth, 270

surgical treatment of, 270
bulbar, following diphtheria, 154
divers', 67
facial, 170

anastomosis of nerves in. 171
bilateral, 171
contraction in, 171
from fright, 172
Paracentesis, 40

Paralysis of abdominal muscles. 166
Brown-Sequard, 165
Erb's, 269
hypoglossus, 172
Landrv's, 166
like that of lead, 172
of larynx. 155
of ocular movements, 153

Paramel rium, rupture into, 236
Paramyoclonus multiplex, 182
Paraplegia, spastic, 166

Paratyphoid and endocarditis, 85
Pathology of heart disease, 88

of newborn infant, 267
Pelves, contracted, version in, 227
Pelvic contraction, induction of labor for,

224
Pemphigus neonatorum, 12!)
Percussion, 44
Pericarditis, 74

caseopurulent mediastino-, 74
purulent, 74
Pericardium, 73

friction sound oxer, 73
normal flaccidity of, 73
pyopneumo-, 74
surgery of, 73
Periodicity of asthma, 55
Pertussis. See Whooping-cough.
Petroleum, crude, 57
Phlebitis migrans, 66
Phlegmasia alba dolens, 262
Phonation phenomena, intercostal, 48
Phonendoscope, 75
Phonomyoclonus, 45
Phthisis. See Tuberculosis.
Physical diagnosis, 44
examinations, 47

of upper (best, 47
signs, 47
Placenta, dangers of Crede's method, 239
new method of expressing, 240
pra?via, 213

Bossi's dilator for. 216
central, 215

relation of, to subsequent preg-
nancies, 238
version in, 214
Pleura, 34

Pleural adhesions, artificial, 38
effusion, 34

cytological diagnosis of, 34
eosinophile, 34
replaced by aseptic air, 36
serofibrinous, 34
syphilitic, 35
treatment of, 36
tuberculous, 35
typhoid, 34
upper edge of, 35
Pleurisy, 34

abdominal pain in, 36
alcohol applications for. 38
auto-serum therapy in, 37
diaphragmatic, 35
Pneumocoecus endocarditis, 85
Pneumoconioses, 49
Pneumonia, broncho-, 18
and pertussis, 49
etiology of, 49
open air for, 49
treatment of. 49
Pneumothorax, 40

clinical forms of. 40
Poliomyelitis. 163
Polycythemia, S3

INDEX.

281

Post-partum hemorrhage, 240
Presystolic murmurs, 80
Pregnancy, 189

an early sign of, 189

and abortion late in life, 194

and chorea, 194

complicated by fibroids, 198

diagnosis of, 189

effect of, on cicatrices in uterus,

237
extrauterine, 190
gonorrhoea during, 258
myasthenia gravis in, 195
pyelonephrosis in, 204
relation of placenta prsevia to sub-
sequent, 238
twin, 190

diagnosis of, 190
Premature labor, induction of, 224
Pressure, arterial, 08, 09
blood, 07

capillary, 71
clinical aspect of, 08
therapeutical aspect of, 09
Procreation of sex at will, 191
Prognosis of syphilis, 141
Prophylaxis of tuberculosis, 18
Pruritus, 127
Psoriasis, 130
buccalis, 130
diffuse, 132
fulness, 130
Psychical relation of tuberculosis, is
Pubiotomv, 228

Gigli's method of, 228
Puerperal breast, staphylococcus infection
through, 204
hsematoma, 200
immunity, 203
infection, 242

bacteriology of, 240, 250, 253
formalin solution for, 244
gonococcus a cause of, 258
hysterectomy for, 254, 258
iodine for, 244, 240
method of infection in, 251
prophylaxis of, 242
rubber glove in, 242, 245
salt solution in, 245
statistics on, 259
tetanus, 200

Murphy's treatment of, 200
Puerperium, abscess of uterus during,
201
gonorrhoea during, 258
pyonephrosis in, 204
Pulmonary hydatids, 53
motility, intrinsic, 41
oedema, 73
regurgitation, 81
valves, 80
Pulsating empyema, 38
Pulse rate in tuberculosis, 33

recorder, 08
Pulsus alterans, 92
bigeminus, 92, 93

and hemisystole, 93
paradoxus, 93

Puncture, exploratory, 36

reflex influence of, 36
Pupil, paradoxical reaction of, L59
Pupillary phenomena, 157
Purin bodies, 71
Purulent pericarditis, 74
Pysemia, treatment of, 258
Pyelonephrosis in pregnancy, 204

in puerperium, 264
Pyopneumopericarditis, 74

and empyema, 74

RADIODERMATITIS, 133
Radiotherapy, 113, 133
in eczema, 113
Radium in dermatology, 131
Raynaud's disease, 65
Rectal thermometry, 33
Reflex, cardiac, 78

influence of puncture, 36
of lung, 42
Regeneration of spinal cord, 169
Registration for tuberculosis, 19
Regurgitation, pulmonary, 81
Respiration, Schultz's artificial, 49
Respiratory exercises in hysteria, 178
inflation of stomach, 37
insufficiency, 60
mechanism, 41

movements, asymmetry of, in hemi-
plegia, 43
tract, malaria of, 53
Retroflexed gravid uterus, incarceration

of, 193
Rheumatic endocarditis, infective nature

of, 80
Rheumatism and endocarditis, 86
antistreptococci serum in, 99
myocardial changes in, 87
Rhythm, abnormalities of cardiac, 90
Rod-auscultation, 40
Root type of sensory disturbances,

104
Rubber gloves, 242, 245
Rupture of aorta, 01
of auricle, 88
of uterus, 232, 236

into the parametrium, 236

SALINE injections in heart disease,
100

Salt solution, formula for, 245
Sanatoria free from infection, 18
Sanatorium and native open air, 25

building, -I

model, 23

percentage of cures in, 23

studies and statistics of, 23

system, 22

treatment of tuberculosis, 21, 22,
24
Sarcoma cutis, 134
Schauta's solution, 244
Schott's treatment, 97
Schultz's artificial respiration. 49
Sciatica, 173
19

282

INDEX.

Sclerosis, lateral, amyotrophic, 162
unilateral. L62
multiple, 166
Scopolamine and morphine narcosis, 238
Sea climate, contraindications to, 26
Sensory disturbances in syringomyelia,

Kit '
Sepsis, puerperal. See Puerperal infec-

t ion.
Serofibrinous pleurisy. 24
Serum, antistreptococcus, 253
in rheumatism, 99
Marmorek's, 27
Trunecek's 6 1, 70
Sex, determination of, 191
Sexes, procreation of, at will, 101
Signs in the upper chest. 17
Skin diseases, adrenalin in, loo

sarcoma of, 134
Soap inunctions for tuberculosis, 31
Sodium cinnamate, 31
Solvin, Muller's. 58
Spa-tic paraplegia, 166
Specific therapy tor tuberculosis, 26
Sphygmomanometer, 68
Spinal cord, diseases of, loo

hemorrhage into cavity of, 1(14
regeneration of, 164
cyst. 160
tumor. 160
Spinalgia in tuberculosis, 34
Spina's saline injection, 100
Spine, injury to. 107
Staphylococcus infection through the

puerperal breast, 264
State prevention of tuberculosis, 18
Statistics on puerperal fever, 259
Stenosis, congenital mitral, 84
of aorta, 60
of arterial system, 62
mitral, and cedema. 72
angina in, 89
Sterilized air in empyema, 40
Stethoscope, a new, 45

Robertson's multiple, 46
Stethoscopy, 45
Stoker's cubicle, 29
Stokes-Adams disease, 90, 94

arteriosclerotic, 94
due to poisons, 94
neurotic, 94
physiological, 94
post -febrile, 94
toxic, 94
Stomach, perforation of heart bv ulcer

of, 89
Streptococcus endocarditis, 86
Sunlight for tuberculosis, 30
Suprarenal extract in dermatoses, 135
Surgery, obstetric, 217
of pericardium, 73
Surgical emphysema, 53

treatment of eclampsia, 211
Suturing, nerve, 173
Symphyseotomy, 227
Syphilis, 86, 138

antiquity of, 138

as a life shortener, 143

Syphilis bacilli, 139

curabilil y of, 1 1'-'

heart. 86

in animals, 139

prognosis, of, 1 1 1

treatment of, 14 1-148
Syphilitic pleural effusion, 35
Syringomyelia, 104

hypertrophy in, 1 65

sensory disturbances in, 164
Systolic murmurs, mitral, 80

TABES dorsalis, 155
accessorius palsy in, 155
cytodiagnosis in, lot>
early, 79, 156
gastric crises in, 155
optic atrophy in, 157
Tachycardia, 95

in tuberculosis, 96

paroxysmal, 95, Oil

permanent, 95

temporary, 95
Tarnier's principle in occipitoposterior

rotations, 223
Taste, condition of, after removal of

Gasserian ganglion, 174
Temperature in tuberculosis, 33
Tent life for tuberculosis, 24
Tetanus, gelatin, 61

Murphy's treatment for, 260

puerperal, 260
Tetany, 180
Therapeutical aspects of blood pressure

in, 69
Therapeutics of lung diseases, 57
Thermometry, rectal, 33
Thieucalyptol, 58
Thorium nitrate, 29
Thrombosis in tuberculosis, 34
Thyroid extract in eclampsia, 213
Tracheo-cesophageal fistula, 57
Tracheotomy, after-history of, 53
Traumatic arhythmia, 91

endocarditis, 86
Treatment of, acid, 101

of aneurysm, 61

of angioma, 104

of asthma. 55

of baldness, 105

of birth palsy, 269

of boils, 120

of brachial birth palsies, 270

of bronchitis, chronic, 50
fetid, 51

of bronchopneumonia, 49

of bronchorrhcea,50

of burns, 107

of caisson disease, 67

of cardiac irregularity, 91

of chancroid, 109

of chloroform syncope, 99

of chromidrosis, 110

of common colds, 54

of cough, 57

of dermatitis venenata, 111

of eclampsia, 206-213

INDEX.

283

Treatment of eczema, 112

of effusion, 36

of empyema, 38

of epithelioma, 115

of erysipelas, 113

of fibroids in pregnancy, 198

of furunculosis, 120

of heart disease, 96
failure, 98

of hiccough, 58

of itching, 126

of lichen planus, 126

of lupus erythematosus, 103, 124
vulgaris, 124

of neuroses, cutaneous, 126

of oedema, 73

of ophthalmia neonatorum, 272

of placenta pnevia, 213

of post-partum hemorrhage, 240

of pruritus, 127

of psoriasis, 131

of puerperal infection, 242-258
tetanus, 261

of pyaemia, 25S

of pyonephrosis in pregnane}-, 264

of rupture of uterus, 232

of syphilis, 144-148

of trichophytosis, 136

of tuberculosis, 20
Trichophytosis, 136
Trunecek's serum, 64, 70
Tuberculin treatment of tuberculosis,

27
Tuberculosis, 17

administrative control of, 18

adrenalin for, 32

altitude climate for, 26

arctic treatment of, 26

arrested, 23

asylum for, 22

bacterial treatment of, 27

bed-punkah for, 28

blood in, 33

campaign against, 17

carbon dioxide for, 31

care of, in the family, 19

climatic treatment of, 24, 25

creosote treatment of, 27

diagnosis, early, 32, 33

dispensary for, 21

etiology of, 32

evils of exercise in, 27

Finsen's rays for, 30

formaldehyde for, 31

garlic for, 32

nigh-frequency currents for, 30

home treatment of, 21

hvgienic treatment of, 27

ichthyol for, 31

individual prevention of, 20

intralaryngeal injections for, 30

iodoform for, 31

isolation of, 18

latent, 20

Marmorek's serum, 27
test for fluids in, 32

medicinal treatment of, 30

natural cure of, 21

Tuberculosis, notification of, 18

open-air cure of, 21

prophylaxis, 18

protection after infection, 21

psychical relations of, 19

pulse rate in, 33

raw meat for, 28
milk for, 28

rectal thermometry in, 33

registration of, 19

remedial treatment of, 21

sanatoria for, 21

sea climate for, 26

soap inunctions for, 31

sodium cinnamate for, 31

specific therapy for, 26

spinalgia in, 34

State prevention of, 18

Stoker's cubicle for, 29

sunlight for, 30

tachycardia in, 96

temperature in, 33

tent life for, 24

thorium nitrate for, 29

thrombosis in, 34

treatment of, 20

tuberculin in, 27

vaccination against, 26

weight in, 34

.x-ray in diagnosis of, 32
Tuberculous bronchiectasis, 51

fluids, test for, 32

meningitis, 150

pleurisy, 35

hyperchloruria in, 35
Tumor, brain, 149

optic symptoms of, 152

cerebellar, 151

spinal, 160

of vertebrae, 161
Twin pregnancy, diagnosis of, 190
Typhoid and endocarditis, 85

effect of, on bloodvessels, 86
on heart, 86

pleurisy, 34

ULCER, gastric, perforation of heart
by, 89
Ulcerative endocarditis, 85
Unexplained dropsy, 72
Uric acid, 71

Uterus, abscess of, during puerperium,
261
bacteriology of the puerperal, 253
incarceration of retroflexed gravid,

193
rupture of, 232, 236

into parametrium, 236

VACCINATION against tuberculosis,
26
Vaginal Cesarean section, 229

for eclampsia, 212
Valves, aortic, 80

pulmonary, 80
Vascular system in eclampsia, 207

284

INDEX.

Vein, thrombosis of jugular, 21
Vena cava, perforation of, 65
Venous murmurs, 82
Veratrum viride in eclampsia, 208
Version in contracted pelves, 227

in placenta prsevia, 214
Vertebra, fracture of, 169
Vertebrae, tumor of, 161
Vesicular murmur, 15
Vessel-crises, 69

Visceral pain, 6!)
Voorhees bag, 218

WEBSTER'S solution, 244
Weight in tuberculosis, 34
Whooping-cough and bronchopneumonia,
49

X-RAY in diagnosis of tuberculosis^
32

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Literature on Application

Sole Agents for the United States

A SYSTEM

OK

PRACTICAL SURGERY

BY

Prof. E. von BERGMANN, M.D.

OF BERLIN
AND

Prof. P. von BRUNS, M.D. Prof. J. von MIKULICZ, M.D.

OF TUBINGEN of breslau

Translated and Edited under the Supervision of
WILLIAM T. BULL, M.D.

Professor of Surgery in the College of Physicians and Surgeons, New York.

//; five imperial octavo volumes containing over JfiOO pages, with about 1600

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